Aug 26, 2025 | Volume 15 - Issue 3
Andie Chilson, Melissa Mecadon-Mann, Rebecca Gwira, Loidaly G. Rosario-Singer
This scoping review examines 12 years of research on body image ideals and eating disorder (ED) pathology in Black American women. The authors synthesized the aims, methods, and results of 10 studies to outline the specific body image ideals within this population and the relationships between these ideals and ED risk. The findings from this review provide important insights to inform counseling and integrated care approaches for working with Black American women struggling with body image and disordered eating. This study highlights the existing evidence on body image and EDs in this understudied population and points to critical directions for future investigation.
Keywords: body image ideals, eating disorders, Black American, women, counseling
Body image as it relates to disordered eating has been a widely researched topic within the medical and psychology fields (Blostein et al., 2017; Brandsma et al., 2019; Jung & Forbes, 2012; Malachowski & Myers, 2013; Mölbert et al., 2018; Reslan & Saules, 2013). Researchers have explored racial and cultural differences in disordered eating pathology and identified specific body image ideals among racial and ethnic communities (Aldalur & Schooler, 2019; Capodilupo & Kim, 2014; Goel et al., 2021). Disordered eating research has primarily focused on Western European, White body image ideals. Therefore, a scoping review was warranted to achieve a comprehensive view of this underexamined topic. According to Arksey and O’Malley (2005), there are four commonly cited reasons to warrant a scoping review: to examine the extent and nature of existing research on a topic; to discern whether a full systematic review is necessary; to summarize and disseminate key findings; and to identify gaps in the existing literature. We have observed a dearth of research on the intersection of body image ideals and eating disorders (EDs) in Black American women and, therefore, endeavored to summarize and disseminate key findings and identify gaps in the existing literature.
Research is limited on the most effective modalities to treat disordered eating in minoritized populations. Cognitive behavioral and dialectical behavioral therapy are among the most popular counseling treatments for disordered eating in clients who are striving for a thin body ideal (Federici et al., 2012; Fursland et al., 2012). However, the body image ideals for Black and African American women differ from their White, Asian, Latine, and Native American peers (Smith et al., 2020; Talleyrand, 2012). Therefore, counseling modalities centered around the thin ideal are not the best fit for Black and African American clients who present with EDs. For example, Labarta and Bendit (2024) suggested a relational–cultural approach to ED treatment that provides space for the decolonization of traditional treatment models. As such, this scoping review was driven by the following research question: What are the most common body image ideals (as they relate to body weight/shape) for Black women living in the United States and how does this impact their risk for/presentation of disordered eating?
Body Image Ideals in Black Women Living in the United States
Studies have shown that Black women may feel less pressure to be thin than their White peers (Awad et al., 2020). Historically, the Black community has seen larger bodies as resilient, healthy, and a symbol of wealth. Awad et al. (2015) identified a thick/toned/curvy body shape as optimal for Black women. Some Black women exercise not to lose weight but to achieve a large backside and a small waist. However, when in a majority White community, the pressure to conform to the thin ideal is still present (Awad et al., 2015). In these instances, diet (or not eating at all) and exercise are emphasized.
The ideal body shape for Black American women also includes acceptance of a larger body size, or what some call the curvy ideal (Boutté et al., 2022; Cotter et al., 2015; Gitau et al., 2014; Hunter et al., 2017; Parker et al., 2022; Scott, 2019). The curvy ideal, sometimes described as a Coke-bottle figure (Hunter et al., 2017), consists of a large bust, a small waist, and a large backside. It has been stated that because Black women have wider acceptance of a larger body size or the curvy ideal, they experience body dissatisfaction less than their White peers (Boutté et al., 2022). It is important to note that the curvy ideal is not necessarily more attainable or healthy than the thin ideal (Scott, 2019). The curvy ideal is also related to body dissatisfaction and can be associated with body monitoring or body checking (Shafran et al., 2003). Body checking, or continual monitoring of weight, waist size, and body measurements, can be a risk factor for developing bulimia nervosa (BN) and anorexia nervosa (AN; Shafran et al., 2003).
Eating Disorder Prevalence and Risk/Protective Factors in Black American Women
The scope of the existing research on ED pathology in Black and African American individuals is extremely limited. The most recent comprehensive study examining the prevalence of EDs in Black Americans was conducted in 2007. The study found that binge eating disorder (BED) was the most common ED among Black adults, comprising 2.24% of participants, and AN was the least common, with 0.17% of adults meeting diagnostic criteria (Taylor et al., 2007). Although this study is extremely useful in providing a point of reference for the prevalence of eating pathology in Black Americans, updated research on the topic is needed.
According to Cotter et al. (2015) and Hunter et al. (2017), Black women have similar rates of disordered eating to their White peers. Many Black women feel an expectation to be thin and/or fit into a specific body ideal; however, there is a lack of research specific to Black women and ED pathology. Additionally, the research that does exist is highly focused on body mass index (BMI) and obesity rates, which have been proven to be poor indices of physical health (Rasmussen, 2019) and fail to address the underlying cause(s) and risk factors of disordered eating in Black communities (Hunter et al., 2017). Black women are often categorized as overweight and/or diagnosed as obese while EDs are likely undiagnosed or underdiagnosed in this demographic (Boutté et al., 2022).
Racial identity development can act as a protective factor against disordered eating (Capodilupo & Kim, 2014; Rakhkovskaya & Warren, 2014). Capodilupo and Kim (2014) found that identification with the majority culture leads to higher levels of disordered eating, while Black women who identify with Black culture have lower levels of body dissatisfaction. As one works through racial identity development, they tend to identify more with cultural norms and push away from the body ideals of White culture and influence. The Black community emphasizes beauty ideals beyond size and shape (attitude, self-confidence, hair; Rakhokovskaya & Warren, 2014). Therefore, rejecting White beauty ideals through racial identity development may protect some women from disordered eating behaviors.
Present Investigation
This scoping review was inspired by a review published by Harris (2015), which explored three different strata of research on EDs in Black American women from 1980–2015. The first stratum of research discusses the clinical implications of the exclusion of Black women from ED research in the 1980s. Harris demonstrated that as ED presentations in Black women became increasingly recognized, the rate of treatment for Black women with EDs similarly increased. However, ED research and treatment at this time still largely centered around economically advantaged White women and the Eurocentric beauty ideals with which they aligned (Harris, 2015).
The second stratum of research highlighted by Harris (2015) emphasizes an expanded definition of body image to include affective, psychological, and behavioral facets, thus creating a more nuanced and inclusive dialogue around the implications of body image concerns for Black women. This expanded definition of body image also opened up the conversation for cultural variables related to body image that could be precursors to EDs in Black women (Harris, 2015).
The third and final stratum of research examined by Harris (2015) saw an increase of within-group studies of Black American women compared to the between-group studies with White and Black women that dominated ED literature up to that point. This stratum of research also identified strong ethnic identity as a protective factor against EDs in Black women, and low ethnic identity as a risk factor for BED and BN symptomatology (Harris, 2015). In the conclusion of the paper, Harris called for further investigation into risk factors associated with eating pathology in Black American women.
The goal of the present investigation, therefore, is to bridge the gap between the findings of the Harris (2015) study and the existing body of research. We endeavored to accomplish this in three ways: first, identify the most common body image ideals for Black women living in the United States; second, identify what relationship (if any) exists between body image and disordered eating in Black women living in the United States; and third, identify implications for counselors based on the research findings of the first two objectives. The language “Black” and “African American” was utilized to capture as many ethnic identities as possible, including those that did not originate in the United States. When articles specified ethnic identities in their demographics, we indicated as such.
Methods
Author Positionality
There were four authors for the present investigation. It is critical to acknowledge that the first and second authors, Andie Chilson and Melissa Mecadon-Mann, are White women who have learned, only as outsiders, about the intersecting experiences of body image challenges and eating disorders in Black American women. Chilson has benefited both directly and indirectly from systemic racism, particularly as it pertains to adherence to Eurocentric beauty ideals and the inherent protection provided in identity. She has extensive experience working with eating disorders and body image challenges in women from diverse racial backgrounds. The second author, Mecadon-Mann, identifies as a cisgender White American woman in a large body. She has experience working with adolescents and emerging adults with diverse ethnic backgrounds and varied body image ideals and disordered eating behaviors. The third author, Rebecca Gwira, identifies as a first-generation, cisgender, Black woman in a mid-sized to large body. She also has experience working clinically with diverse eating disorder patients across demographic characteristics and levels of care. Her research centers marginalized voices, specifically Black women’s eating and body image concerns and intersectional stress. The fourth author, Loidaly G. Rosario-Singer, identifies as a cisgender Puerto Rican woman; she has benefited from some aspects of Eurocentric body ideals because she has had a small to mid-sized body the majority of her life. She has experience working with multilingual children and families with a focus on health equity and reproductive justice.
Methodology
The following research questions guided this scoping review:
RQ1: What specific body ideals are most commonly endorsed by Black American women, and how do these ideals differ from or align with the thin ideal traditionally emphasized in ED research?
RQ2: What (if any) relationship does the existing literature identify between culturally specific body image ideals and the manifestation of different types of disordered eating behaviors in Black American women?
RQ3: Identify implications for counselors based on the research findings of the first two objectives.
Our systematic search was conducted based on the guidelines put forth by the PRISMA extension for scoping reviews (PRISMA-ScR), a 22-item checklist aimed at helping readers develop a better understanding of the terminology and key concepts reported in scoping reviews (Tricco et al., 2018). The checklist was created by a panel of 24 expert members and two research leads and was informed by the published guidelines of the EQUATOR (Enhancing the QUAlity and Transparency Of Health Research) Network (Tricco et al., 2018). A five-step scoping review process was undertaken, including 1) identifying the research question and objectives; 2) defining the scope of the review; 3) selecting the records; 4) charting the data; and 5) summarizing the results. Inclusion and exclusion criteria were identified a priori and documented in a protocol.
Eligibility Criteria
The eligibility criteria for inclusion were based on population (P)—Black American women; exposure (E)—body image ideals; and outcome (O)—disordered eating. To attempt to capture all relevant literature published after or around the time of Harris (2015), articles published in English between 2013 and 2025 were eligible for inclusion in this review. Sources examining a pediatric population (under 18 years) or research conducted outside of the United States were excluded from the review.
Information Sources
Inclusion and exclusion criteria were established a priori with the assistance of a public health librarian at Western Carolina University. These criteria were used to develop a standard checklist for study eligibility for screening titles/abstracts and subsequently full-text sources. All stages of the screening process were conducted using Covidence, an online software tool used to organize records in the systematic or scoping review process and to blind the results between the researchers. Study selection was conducted independently by Chilson and Mecadon-Mann based on the preestablished checklist. All decisions were automatically recorded via Covidence. Conflicts between the authors were resolved through discussion. Records were identified through searching the following electronic databases: Academic Search Premier, Biological & Agricultural Index Plus (H.W. Wilson), Business Source Premier, Child Development & Adolescent Studies, CINAHL Plus with Full Text, Communication & Mass Media Complete, eBook Collection (EBSCOhost), Education Source, ERIC, Gender Studies Database, Health Source: Nursing/Academic Edition, MasterFILE Premier, MEDLINE Complete, Mental Measurements Yearbook with Tests in Print, Military & Government Collection, Philosopher’s Index, APA PsycArticles, APA PsycInfo, APA PsycTests, SocINDEX with Full Text, SPORTDiscus with Full Text, and Ebony Magazine Archive.
Search
To achieve an extensive review on the topic, literature from the past 12 years was included in the search. Because of limitations with access to sources outside of Western Carolina University, reference mining was not conducted as part of the present study. The search strategy was created by a public health librarian at Western Carolina University in collaboration with Chilson. The search strategy was checked for comprehensiveness and errors against the PRESS Peer Review of Electronic Search Strategies Guidelines. The specific search terms utilized were as follows: (Black OR Blacks OR African American*) AND (female* OR woman* OR women* OR lady OR ladies* OR gyn* OR girl*) AND (“eating disorder*” OR “disordered eating” OR anore* OR “binge eating” OR bulimi* OR purging OR purgeing OR “restrictive eating” OR orthore* OR overeat* OR pica) AND (body OR personal) AND (image OR perception OR satisfaction OR dissatisfaction OR psychosocial OR societ*).
Data Charting Process
A data extraction template in Covidence was used to record key characteristics and relevant information from eligible records, including study design, research purpose, study participants, and research findings/results. Chilson and Mecadon-Mann independently charted the data, discussed the results, and regularly updated the data extraction form in Covidence.
Data Items
Chilson and Mecadon-Mann abstracted data on article characteristics (i.e., country of origin, publication date, language), sample characteristics (i.e., race, gender, and age), and constructs/outcomes examined (i.e., body image ideals and EDs). Gwira subsequently vetted all the extracted articles based on the same criteria.
Critical Appraisal of Individual Sources of Evidence
An in-depth examination of the unique body image ideals held by Black women and their influence on the risk for EDs is lacking in the current literature. Therefore, we endeavored to explore the link between specific body image ideals of Black women and their correlation with EDs. We also aimed to identify the most common body image ideals for Black women living in the United States as an independent construct. Individual articles were screened for eligibility using the systematic review management tool, Covidence. Chilson and Mecadon-Mann independently screened the articles against inclusion/exclusion criteria, which were established a priori. We then screened articles at the abstract level for general relevance and subsequently conducted full-text screenings. Articles included in the full-text screening were assessed to determine if sources examined Black American women, specifically; examined body image ideals, specifically, or body image ideals as an independent variable and ED as a dependent variable; and examined an adult sample (18 years or older) from the United States. After reviewing at the full-text level to determine that Black American women, specifically, were examined, Chilson and Mecadon-Mann looked for language such as Black American, African American, Caribbean American, and Haitian American to encompass the full spectrum of Black American women. Also at the full-text level, we screened for clearly identified body image ideals, which required reference to a preferred size/shape of a specific body part (e.g., Coke-bottle waist; Hunter et al., 2017) or preferred shape of the body, generally (e.g., curvy ideal; Scott, 2019). If the intersection of an ED was present, Chilson and Mecadon-Mann screened for either general reference to ED (e.g., “ED pathology”; Siegfried, 2021) or specific reference to an ED diagnosis (e.g., anorexia and bulimia; Hunter et al., 2017). Gwira screened each source separately against the established inclusion/exclusion criteria and charted assessments in an Excel spreadsheet. Gwira and Rosario-Singer reviewed the manuscript for accuracy and offered feedback for Chilson and Mecadon-Mann’s consideration.
Synthesis of Results
The synthesis included quantitative analyses (e.g., means, standard deviation) to summarize the characteristics of included records, body image ideals in Black women, and any ED intersection noted. The results are presented in both a table and a descriptive format that aligns with the review’s objectives of identifying the most common body image ideals for Black women living in the United States and identifying the relationship between body image and disordered eating in Black women living in the United States.
Results
The record identification process is outlined in Figure 1. A total of 501 records were identified through the initial search process. After removing all duplicates (n = 301), the authors were left with 200 records for screening. Next, 107 records were excluded based on criteria such as examination of a pediatric population (under age 18), women outside of the United States, and a lack of focus on Black women. There were 93 records then screened for eligibility, 83 of which were excluded because of patient population, type of publication, and lack of access. This process resulted in 10 records selected for inclusion.
Figure 1
PRISMA Flow Diagram for Scoping Reviews
Note. Adapted from Page et al., 2021.
Characteristics of the Sources of Evidence
Included records examined Black women living in the United States. One study (Bruns & Carter, 2015) also examined White women, and another study (Siegfried, 2021) examined Hispanic/Latina/x women in addition to Black women. Participant ages ranged from 18–73 years and there was no discernible trend in the age selection of the included records. Only one study specifically examined a sample of women 25 years and older (Talleyrand et al., 2016). The majority of records included the age range with mean/standard deviation, except two papers, which only reported the age range and not the mean/standard deviation (Bruns & Carter, 2015; Siegfried, 2021).
Included study designs were qualitative research (n = 4), randomized controlled trial (n = 2), cross-sectional (n = 2), mixed methods (n = 1), and exploratory factor analysis (n = 1). The 10 included records presented data from sample sizes ranging from 11 to 232. Two studies (Awad et al., 2015; Hollier, 2019) were conducted with women enrolled in universities across the United States. One study (Talleyrand et al., 2016) was conducted in the greater Washington metropolitan area. The other seven studies did not specify where they were conducted within the United States.
Four studies utilized focus group questions aimed at identifying common themes pertaining to beauty ideals specific to Black women. Two studies used the Eating Disorders Inventory – 3 (Garner, 2004) to determine specific body image ideals and assess for the presence of ED pathology. Two studies employed the Eating Attitudes Test – 26 (Garner et al., 1982) to measure disordered eating behaviors. Other instruments utilized in the included studies were the Contour Drawing Rating Scale (n = 2; M. A. Thompson & Gray, 1995), The Skin Color Satisfaction Scale (n = 1; Falconer & Neville, 2000), The Reese Figure Rating Scale (n = 2; Patt et al., 2002), the Rosenberg Self-Esteem Scale (n = 2; Rosenberg, 1965), Family Experiences Related to Food Questionnaire (n = 1; Kluck, 2008), Family Food Experiences-Black Questionnaire (n = 1; Hunter et al., 2017), Body Image Disturbance Questionnaire (n = 1; Cash et al., 2004), Visual Analog Scale- Body Satisfaction (n = 1; Heinberg & Thompson, 1995), The Curvy Ideal Silhouette Scale (n = 1; Scott, 2019), Curvy Ideal Questionnaire (n = 1; Scott, 2019), The Sociocultural Attitudes Towards Appearance Questionnaire—3rd Edition (n = 1; J. K. Thompson et al., 2004), The Sociocultural Attitudes Towards Appearance Questionnaire—4th Edition (n = 1; Schaefer et al., 2015), Objectified Body Consciousness Scale (n = 1; McKinley & Hyde, 1996), Body Shape Questionnaire (n = 2; Cooper et al., 1987), Eating Disorder Examination-Questionnaire (n = 1; Fairburn, 2008), and Gormally Binge Eating Scale (n = 1; Gormally et al., 1982).
Table 1
Results of Individual Sources of Evidence
| Author(s), Publication Date |
Aim of Study |
Study Participants |
Study Design |
Body Image Ideals |
Eating Disorder Intersection |
| Awad et al., 2015 |
Examine the issues that arise pertaining to AA women’s conception of beauty and body image, identify body image themes, and identify the sources of the body image messages received and internalized. |
Female AA students enrolled in a large Southwestern university in the United States between the ages of 19–25 |
Qualitative research |
Thick/toned/curvy as optimal
(n = 33) |
Yes |
| Bruns & Carter, 2015 |
Examine how model ethnicity and body shape impact body dissatisfaction. |
Women self-identifying as African American or Caucasian between the ages of 18–45 |
Randomized controlled trial |
Thin ideal and plus-sized ideal |
No |
Capodilupo
& Kim, 2014 |
Explore how race and gender interact and inform body image ideals. |
Women between the ages of 21–35; identified as African American (n = 10), Black American (n = 4), Caribbean American (n = 4), and Haitian American (n = 2); six women did not specify their ethnicity |
Qualitative research |
Large breasts, shapely hips, and full backside |
No |
| Hollier, 2019 |
Examine body dissatisfaction and self-esteem factors that contribute to BEDs among Black female students. |
Black college women currently enrolled in a private or public university in the United States between the ages of 18–54. All participants self-identified as “Black,” but 3.2% of the participants identified as “other” and “multi-racial” under this umbrella |
Cross-
sectional |
Thighs, breasts, waist/hip ratio |
Yes |
| Hunter et al., 2017 |
Explore family food experiences (FFEs) of AA women and develop a measure of FFEs related to disordered eating. |
Studies 1 & 3: AA women from two National Pan-Hellenic Council sororities at a Southeastern university; Study 4: AA women from across the United States younger than 25 |
Mixed methods |
“Boobs and booties” (Study 1) and “Coke-bottle figure” (Study 3) |
Yes |
| Author(s), Publication Date |
Aim of Study |
Study Participants |
Study Design |
Body Image Ideals |
Eating Disorder Intersection |
| Javier, 2017 |
Increase understanding of body image and eating behaviors in AA and Asian American women. |
Study 1: AA women between the ages of 18–30 who reported body image problems |
Qualitative research |
Curvy and thin ideals |
Yes |
| Scott, 2019 |
Examine the effect of exposing Black women to rap lyrics that promote the curvy ideal on their level of body image dissatisfaction. |
Black women between the ages of 18–34 who had access to audio output (e.g., headphones, speaker); all participants identified as AA, 2.1% also identified as American Indian/Alaska Native, and 4.2% also identified as White |
Randomized controlled trial |
Curvy ideal |
No |
| Siegfried, 2021 |
Increase understanding of the ways cultural values and pressure impact the development of EDs in Black and Latinx women in the United States. |
Black, Hispanic/Latina/x, and Afro-Latina/x women between the ages of 18–25 living in the United States; 125 participants (49.2%) identified as Black, 107 (42.1%) identified as Hispanic or Latina/x, and 22 women (8.7%) identified as Afro-Latina/x |
Cross-sectional |
Thin ideal |
Yes |
| Talleyrand et al., 2016 |
Explore the phenomena that impact body image ideals, eating behaviors, and appearance in AA women over the age of 25 who report body/weight concerns. |
AA/Black women in the greater Washington metropolitan area; seven women identified as African American, two identified as Black, and two identified as African American/Black. |
Qualitative research |
Thin, sculpted “ripped” arms, and “sistah girl” hips |
No |
| Wilfred & Lundgren, 2021 |
Assessing the psychometric properties and validity of a body image assessment
for Black women. |
Women between the ages of 18–73 who identified as African American (73.4%), African (8.5%), Afro-Latina (3.5%), Caribbean (1.5%), Caribbean American (1.5%), other Black descent (3.0%), and multiple racial identities (8.5%) |
Exploratory factor analysis |
“Slim-thick,” thin, and muscular |
Yes |
Main Study Outcomes
The most salient findings of the current study were twofold: first, the identification of specific body ideals held by Black women living in the United States; and second, the identification of a relationship between specific body image ideals and the presence of ED behaviors in Black women living in the United States. The first predominant body image ideal identified was a thick/slim-thick/curvy ideal. The majority of the included records indicated a striving for the curvy ideal (i.e., large breasts, shapely hips, and large backside) as opposed to the more commonly cited thin ideal. Four studies identified specific body parts that were highlighted as part of the curvy ideal. For example, Hunter et al. (2017) discussed “boobs and booties” (p. 29) as two specific body parts on which Black women focused their attention when striving for the curvy ideal.
Although the curvy ideal was the predominant body shape ideal that was identified in the included records, the influence of the thin ideal was also present. Five studies highlighted the influence of the thin ideal on their sample populations, either on its own or in conjunction with the curvy ideal (e.g., Bruns & Carter, 2015). The final body image ideal noted in the included records was the muscular/toned ideal. Both Talleyrand et al. (2016) and Wilfred and Lundgren (2021) identified being visibly fit, toned, or muscular as desirable qualities for Black women. Talleyrand et al. described the desirability of Michelle Obama’s “ripped” arms, stating that she was the ideal combination of curvy and healthy. Wilfred and Lundgren identified a similar muscular internalization, specifically regarding having a toned abdomen as a desirable physical trait for Black women.
The second major finding was that the majority of included records reported a relationship between specific body image ideals and the presence of an ED. More specifically, six out of the 10 included records noted this positive relationship (see Table 1 for specific studies). Hunter et al. (2017) identified an increased risk for AN and BN among Black women in a sorority who idealized being curvy, but only in certain places. Additionally, Awad et al. (2015) described the relationship between experiencing discrimination and the presence of disordered eating behaviors. Both Awad et al. and Javier (2017) found that a disconnect between one’s cultural heritage and the ideals of the White dominant group often led to disordered eating behaviors. If one perceives that they are divergent from the ideals of the dominant group (i.e., the thin ideal), they are likely to engage in potentially harmful disordered eating patterns. Finally, Wilfred and Lundgren (2021) found that the experience of a double consciousness (i.e., the pressure to adhere to two separate cultural ideals) increased ED pathology, specifically BED, among Black women.
Several of the included articles correlated variation in skin tone with positive/negative body image and ED pathology. Wilfred and Lundgren (2021) and Hollier (2019) noted that pressure to meet White body image ideals, including a fair complexion, increase the risk for ED behaviors, BED in particular. Similarly, Awad et al. (2015) determined that women who experienced discrimination stress, dissonance between the dominant culture and their culture of origin, or identification as a devalued group by the majority culture were at an increased risk for ED pathology. Awad et al. (2015) used the example of having a darker complexion to illustrate this, noting that if a woman was darker complected than her peers, and felt devalued because of it, she was more likely to engage in ED behaviors. Capodilupo and Kim (2014) discussed the influence of skin tone in a similar manner, asserting that women who are lighter complected are more likely to be desired by Black men and are more frequently and positively portrayed in the media, decreasing their risk for poor body image and ED behaviors.
The authors also examined moderating factors such as level of education, profession, and socioeconomic status, and found that only one study (Siegfried, 2021) examined the relationship between education and body image/ED pathology and determined that there was no substantial correlation with any of the measures. However, significantly, Siegfried (2021) determined that higher income was highly correlated with lower levels of acculturative stress as well as lower levels of internalization of the thin ideal but noted that there was no predictive factor between income and ED pathology.
Discussion
This scoping review centered around four objectives: first, to identify the most common body image ideals for Black women living in the United States; second, to identify what relationship (if any) exists between body image and disordered eating in Black women living in the United States; third, to bridge the gap between the findings of the Harris (2015) study and the current body of research; and fourth, to identify implications for counselors based on the research findings.
Common Body Image Ideals
Although some Black women in the United States are driven by the thin ideal, many describe a thick, toned, or curvy body shape as ideal. Most of the examined studies identified the thin ideal in combination with the curvy ideal as most desirable among the examined population. For example, Wilfred and Lundgren (2021) identified a “slim-thick” figure, high muscularity, and thinness as the predominant body ideals for Black women. Only one study, Siegfried (2021), identified thinness alone as the predominant body ideal. It is notable, however, that 50% of the included records highlighted thinness as a prominent body ideal for Black women. Although it has previously been assumed (Bruch, 1966) that Black women did not value thinness, the present findings indicate that this is not the case. Although Black women overwhelmingly value thinness in conjunction with the curvy ideal, thinness alone is still emphasized as a desirable quality.
Black American Body Image and Disordered Eating
Black women have lower rates of body dissatisfaction than their White peers but comparable rates of disordered eating. However, Black women have also been associated with disordered eating behaviors that center around culturally specific ideals or factors. For example, Siegfried (2021) described the positive relationship between acculturative stress and the internalization of the thin ideal, which then positively predicts an increased risk for ED pathology. Siegfried further identified a relationship between the internalization of the thin ideal and the development of BN, specifically.
One of the overarching messages regarding the relationship between specific body image ideals and disordered eating in Black American women was that being discrepant from one’s identified cultural ideals was a significant risk factor for disordered eating behaviors (Awad et al., 2015; Hollier, 2019; and Javier, 2017). For example, if an individual strongly identifies with a culture that emphasizes the curvy ideal and they naturally have a curvy figure, they are less likely to engage in disordered eating behaviors to alter their body shape. If an individual with the same curvy figure has a low degree of cultural identity, or identifies more strongly with another culture that emphasizes the thin ideal, they would be at increased risk to engage in disordered eating behaviors. Additionally, women who feel pressured to conform to the body ideals of two cultures are at an increased risk for eating pathology. This experience is referred to as double consciousness (Du Bois, 1903), which in this context means being made to feel like one needs to adhere to the beauty ideals of both mainstream (White European) culture and Black culture.
Gaps in Existing Literature
Although the included records identified general body image ideals that are emphasized by Black American women, there was a dearth in the existing literature surrounding specific ED diagnoses that are linked with certain body image ideals. In the present investigation, only three of the included records identified a specific diagnosis that is linked with certain body image ideals in Black American women. Therefore, future research is warranted surrounding specific ED diagnoses and the associated prevalence rates in this demographic. We also identified that many Black women perceive beauty through a wider lens than simply body shape/size, including elements such as skin tone, hair (length, style, neatness), self-esteem, and attitude. Further investigation into these ideals will deepen the conceptualization of beauty and attractiveness ideals in Black women living in the United States today. Finally, the authors also identified a gap in recent literature examining moderating factors such as level of education and profession that may serve as risk/protective factors for ED behaviors. Further investigation into these factors is warranted to broaden the conceptualization of ED presentations in Black women.
Additionally, there is a gap in the current research surrounding disordered eating and body image ideals in Black LGBTQ+ women, specifically. The studies included in the present investigation either excluded discussion of sexuality entirely or conceptualized it in relation to the male gaze. Therefore, further research into the relationship between sexuality and body image ideals/disordered eating in Black American women is warranted. Another identified gap in the existing literature centers around the influence of the Black/White male gaze on Black women’s self-identified body ideals. More specifically, research is warranted surrounding whether there are different body image ideals for Black women who identify more closely with the body shape/size preferences of Black men compared to White men, and any eating pathology associated with these ideals.
Implications for Counseling and Integrated Care
Traditionally, there has been a limited focus on Black women and ED behaviors outside of the thin ideal. Counselors and care providers must be aware of the culturally embedded protective factors (e.g., racial identity development) that can support healthy eating patterns as well as potential risk factors. It is common for Black women to have higher body weight and BMI, but this does not mean they are immune from disordered eating. It is important to explore how stress and trauma may affect restriction and eating patterns (Small & Fuller, 2021). Boutté et al. (2022) suggested that care providers utilize strengths-based interventions that are holistic rather than interventions focused solely on diet and exercise. It is important, also, to assess for disordered eating before making recommendations to lose weight or form a weight loss plan. Counselors and other helping professionals should consider the implications of skin tone when supporting Black women. As previously noted, darker complected women who exist in a dominant White culture may be at a higher risk for poor body image and ED behaviors (Awad et al., 2015; Capodilupo and Kim, 2014; and Wilfred and Lundgren, 2021). The influence of White, Eurocentric beauty standards on Black women of varying skin tones should be accounted for when conceptualizing treatment plans.
Labarta and Bendit (2024) suggested the use of an integrated relational–cultural approach to ED treatment. Relational–cultural theory (RCT) is rooted in feminist and multicultural theory with a central goal of connection, mutuality, and relationship (Jordan, 2017). RCT approaches to ED treatment allow the care provider and client to work in mutuality, break down power differentials, and repair relationships with food and the body. This framework provides space for discussion and healing focused on racial and social marginalization and how it affects body dissatisfaction, thus building self-image and resilience and empowering clients to live authentically. Further, Labarta and Bendit suggested a self-compassion approach to help clients build knowledge and skills about self-compassion, common humanity, and mindfulness. These factors are helpful in building resilience and can serve as protective factors for people from marginalized communities.
Lastly, care practitioners should be trained in holistic approaches and cultural humility (Matthews et al., 2021). One way practitioners can do this is through expanding care services into the communities where marginalized people live and work. For example, community outreach partnerships can be made with organizations that promote Black female health and wellness. Additionally, practitioners should read literature and attend professional development presented by Black women. One suggested book is Treating Black Women with Eating Disorders (Small & Fuller, 2021).
Strengths and Limitations
This review outlines research spanning a 12-year timeframe, providing a bridge to the anchor article written by Harris (2015). Because of reasons outside of our control, there were a handful of articles that were inaccessible. Furthermore, because of these constraints, we did not conduct reference mining as part of the search strategy. These articles may have added to the findings of the present study. We utilized Covidence software to review articles and lessen the chance of reviewer bias. After consensus was reached between Chilson and Mecadon-Mann, Gwira and Rosario-Singer provided insight into the articles and cultural implications of the research. However, bias is still a possibility in identifying terms and phrases that allude to body image satisfaction or dissatisfaction. An additional limitation is that this review only examined cisgender women. Research examining body image ideals and eating disorder prevalence in individuals outside of the gender binary is needed. The most substantial limitation is the dearth of research specifically focused on body image and EDs in Black women. Therefore, the authors identified a need for ED research and practice publications specifically focused on treating Black women in the United States.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Andie Chilson, MS, LGPC, is a psychotherapist at Greenhouse Psychotherapy. Melissa Mecadon-Mann, PhD, NCC, LPC, LSC, is an assistant professor at Western Carolina University. Rebecca Gwira, PhD, is a clinical postdoctoral fellow at the University of North Carolina at Chapel Hill School of Medicine. Loidaly G. Rosario-Singer, PhD, NCC, LCMHC-A, is Founder and Mental Health Consultant of De Colores Family Wellness. Correspondence may be addressed to Andie Chilson, 1519 Connecticut Ave NW, Washington, DC 20036, andie@greenhousepsych.com.
Aug 26, 2025 | Volume 15 - Issue 3
Kathleen L. Grant, Alyson Pompeo-Fargnoli, Melissa A. Alvaré
The climate crisis is having a significant impact on development and wellness. Young adults face challenges that no earlier generation has experienced, impacting their path toward wellness and thriving. This hermeneutic phenomenological study endeavored to illuminate the experiences of a group of environmentally aware young adults through semi-structured interviews. Thematic analysis, analyzed through Arnett’s theory of emerging adulthood, illustrated participants’ experiences of fear for the future, anxiety, and loss; limited coping strategies for dealing with climate-related emotions; and a perceived tension between their desire to make life choices aligned with their environmental values and a financially stable career. Recommendations for counselors to best serve this population included increasing counselors’ mental health literacy, developing specific strategies to support resilience, and exploring counselors’ ethical responsibilities as advocates.
Keywords: climate crisis, young adults, phenomenological, environmental values, resilience
The climate crisis is expected to have a profound impact on human life in the 21st century (Wuebbles et al., 2017). Evidence of the changing environment is evident everywhere, including historic storms, catastrophic wildfires, record-breaking heatwaves, and severe droughts (Intergovernmental Panel on Climate Change [IPCC], 2023). Americans increasingly believe that the climate crisis is impacting their mental health, with 57.9% of 16–25-year-olds very or extremely worried about climate change, and 38.3% indicating that feelings about climate change negatively impact their daily life (Lewandowski et al., 2024). The consequences of the climate crisis are predicted to continue profoundly impacting mental health (Clayton et al., 2021; Hickman et al., 2021; Sturm et al., 2020).
Definition of the Climate Crisis
The climate crisis poses a significant threat to the future of human civilization. Each day, millions of tons of man-made greenhouse gases, including carbon dioxide (CO2) and methane, are released into the atmosphere (Wuebbles et al., 2017). Burning fossil fuels, such as oil and natural gas, to fuel modern lifestyles is one of the most significant sources of pollution that contributes to global warming (IPCC, 2023). As greenhouse gas emissions rise, global temperatures exhibit a corresponding increase, leading to sea level rise, heat waves, floods, droughts, and severe storms (IPCC, 2023). In 2014, the United States Department of Defense reported that climate change “will likely lead to food and water shortages, pandemic disease, disputes over refugees and resources, and destruction by natural disasters in regions across the globe” (Banusiewicz, 2014, para. 3). By 2050, anywhere from 200 million to 1 billion people will be displaced from their homes, communities, and possibly countries because of climate-related events such as extreme heat, flooding, and famine (IPCC, 2023). For over three decades, the scientific community has warned of the grave danger of global warming and climate change (Borenstein, 2022). Despite the dire warnings, global greenhouse gas emissions continue to increase (World Meteorological Organization, 2020). Young adults are inheriting a world full of unprecedented and complex challenges (Hickman et al., 2021).
Impact of the Climate Crisis on Young Adults
A growing body of literature is documenting the impact of the climate crisis on mental health and wellness, particularly among young people and young adults (Clayton et al., 2021; Hart et al., 2014; Hickman et al., 2021; Sturm et al., 2020). Youth, as defined by the United Nations, encompasses individuals aged 15–24, although this definition may vary (United Nations, 2025). This age range also consists of those emerging adults in the unique developmental period of transitioning from adolescence to adulthood (Arnett, 2000). According to a large study (N = 10,000) published in The Lancet, 77% of young people (aged 16–25) surveyed reported that they think the future is frightening, and 45% indicated that their feelings about climate change had a negative impact on their daily lives (Hickman et al., 2021). Research illuminates how experiencing the direct impact of climate change, such as exposure to wildfires, floods, and displacement, can lead to acute anxiety-related responses and chronic and severe mental health disorders (Clayton et al., 2021; Watts et al., 2015).
Climate change and related disasters can cause direct anxiety-related responses and chronic and severe mental health disorders (Pihkala, 2020). A 2018 meta-analysis found an increased incidence of psychiatric disorders and psychological distress in populations exposed to environmental disaster (Beaglehole et al., 2018). Flooding and prolonged droughts have been associated with elevated anxiety levels, depression, and post-traumatic stress disorders (Hickman et al., 2021). Even among members of the population who have not been directly exposed to the impacts of climate change, such as environmental-related disasters, a simple awareness of the problem may evoke feelings of anger, powerlessness, fear, and exhaustion (Moser, 2007).
Emerging research has highlighted the mental health impact of the indirect effects of the climate crisis, such as climate anxiety (Clayton et al., 2021; Hickman et al., 2021; IPCC 2023). Climate anxiety is a response to the current and future threats of a warming planet (Clayton et al., 2021; Hickman et al., 2021). The associated feelings can include grief, fear, anger, worry, guilt, shame, and despair (Clayton et al., 2021; Doherty & Clayton, 2011). It is essential to acknowledge that scholars recognize anxiety as a natural condition of living and acknowledge its potential benefits, as it can motivate individuals to take action and effect change (Hickman et al., 2021). Climate anxiety, although it can be a complex and intense experience, can also be viewed as a congruent response to the dangers and challenges that global citizens will face now and in the future (Hickman et al., 2021).
Young people with marginalized identities will face the most devastating impacts of climate change (Watts et al., 2015). Low-income and Black, Indigenous, and other communities of color are often the most vulnerable to the worst impacts of climate change, such as flooding, drought, fire, and extreme heat (IPCC, 2023). Furthermore, because of intersectional marginalization, some individuals will be at even greater risk for severe impacts and negative mental health consequences (Hayes et al., 2018). Marginalized communities may lack access to mental health resources after traumatic weather-related events or to process the ongoing challenges associated with climate change (Hilert, 2021). The cultural stigma that reduces help-seeking behavior and lack of access to mental health services may also lead marginalized groups to suffer more from poor mental health outcomes (Priebe et al., 2012).
Research indicates that young people are particularly vulnerable to the adverse effects of climate change, largely because of their ongoing physical and mental development, their dependency on adults, and their likelihood of repeated exposure to climate-related events over time (Hart et al., 2014). However, there is a need for more research on the impact of climate change on mental health, especially as it impacts young people (Hickman et al., 2021). The counseling literature has a paucity of studies in this area (Hilert, 2021; Mongonia, 2022). As the impacts of the climate crisis continue to grow more severe, the profession must deepen its understanding of the climate crisis’s effects on young adults and explore paths toward resilience and wellness (Hickman et al., 2021).
Climate-Aware Counselors
There is a growing need for counselors who are aware of and trained in the mental health impacts of the climate crisis, including climate anxiety (Hilert, 2021). This form of counselor competency includes identifying clients who are experiencing climate-based distress and anxiety (Mongonia, 2022). Although climate anxiety has yet to receive a formal classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM), it is well accepted by counselors as a fear of impending environmental collapse that elicits strong and sometimes debilitating anxiety (Thomas & Benoit, 2022). Counselors must be able to assess and understand how to treat those who present with clinically significant levels of climate anxiety that interfere with functioning and developmental tasks (Pihkala, 2020). Treatment modalities often include teaching resilience and coping skills and increasing support systems (Baudon & Jachens, 2021). Counselors are called upon to support not only their clients through their environmental action but also to take action themselves (Thomas & Benoit, 2022).
Environmental Action
One intervention that can promote positive mental health outcomes for young adults concerned about the climate crisis is climate activism or sustained efforts to effect positive change (Gislason et al., 2021). Young people have been at the forefront of creating new U.S. climate policy (see Sunrise Movement; Bauck, 2022) and driving action (Rashid, 2023). Climate action can positively bring about necessary social change and provide mental health benefits (Hart et al., 2014). Research suggests that young people engaged in climate action experience several benefits, including increased resilience, agency, a sense of purpose, and community, all of which support positive mental health outcomes (Gislason et al., 2021). However, focusing on the climate crisis can also expose individuals to difficult feelings, such as fear, sadness, loss, and hopelessness (Hickman et al., 2021). It is common for people to employ defense mechanisms, such as denial and minimization, to maintain more positive feelings and a more optimistic view of the future in response to the realities of a changing world (Doherty & Clayton, 2011).
Environmentally Aware Young People
Environmental awareness can be broadly characterized as a level of consciousness concerning the importance of the natural environment and the impact of humans’ behavior on it (Ham et al., 2016). Environmental awareness often leads to a deeper understanding of the severity of climate change and the urgency to address it (Orunbode et al., 2019). Youth awareness of the climate crisis is associated with a range of emotional and mental health impacts, such as climate anxiety and feelings of grief, loss, anger, guilt, and existential dread (Hickman et al., 2021). However, environmental awareness can also lead to increased action, a sense of purpose, and resilience building (Clayton et al., 2021).
In the 2024 American Climate Perspectives Survey, Americans aged 18–24 reported the highest levels of environmental concern among all age groups (over 80%; Speiser & Ishaq, 2024). Concern over the environment drives some young adults to action, but not all. Scholars suggest that to prevent the most severe consequences of climate change, humans must take action and alter their ways of life (IPCC, 2023; Wuebbles et al., 2017). Environmental awareness and action will be increasingly important as the impact of the climate crisis grows more pervasive and severe (IPCC, 2023). Young adults, in particular, may need to take steps to adapt to the rapidly changing planet. This study involves young people who are aware of the climate crisis, are motivated to act, and have taken a step toward creating change.
Aims of Study
This study focuses on the experiences of U.S.-based environmentally aware young adults who are moved to take action, aiming to understand their lived experiences as they transition from adolescence into adulthood. This is a significant period in life, as many young people are culminating their educational experiences and choosing who they want to be as adults, both personally and professionally (Arnett, 2014). The research questions guiding this study are: What are the lived experiences of environmentally aware young people as they transition to adulthood? How have their experiences impacted their mental health and understanding of themselves and their roles? How are their environmental experiences influencing their actions and aspirations for their futures (e.g., familial and career goals)?
Method
Hermeneutic phenomenology is a constructivist approach that scrutinizes individuals’ subjective experiences and their interpretations of those experiences, asking “what is the nature of this experience from the individual’s perspective?” (Moustakas, 1994; Ramsook, 2018). The study focused on interpreting the meaning of the lived experiences of the participants, which is crucial given that the experience of entering adulthood during the climate crisis is novel and new structures to understand the nature of this experience may be necessary. Climate engagement for emerging adults involves layered emotions, developmental stage influences, and societal pressures (Arnett, 2010; Clayton et al., 2021; Ogunbode et al., 2019). Hermeneutic phenomenology is well suited to context-rich experiences that cannot be separated from the social, political, and developmental realities in which they occur (Ramsook, 2018; van Manen, 1997). This method enabled us to explore not only what the participants said, but also how they understood themselves in this particular life stage.
Theoretical Framework
Arnett’s developmental theory of emerging adulthood provided the framework for this study. According to this theory, between the ages of 18 and 29, young people consolidate their identity and explore career paths (Arnett, 2000, 2014). This is a time of possibility, in which multiple futures are open, and instability, as individuals transition from the structure provided by their family of origin and formal education and endeavor to make career and personal choices aligned with their values and aspirations (Arnett, 2000). Social and cultural factors also influence young people as they crystallize their identities and career paths (Arnett, 2010). This theory was selected because we were interested in the dynamic interactions among experiences, emotions, and actions within a critical developmental period and how these factors shape participants. Arnett’s theory and hermeneutic phenomenology both emphasize process, interpretation, and the evolving nature of identity within a specific context.
Participants
Twelve interviewees, aged 20 to 25, participated in this research. All participants viewed climate change as an important issue and engaged in environmental action, although their methods for addressing it varied. There were seven female and five male interviewees. The majority identified as non-Hispanic White Americans, but two individuals described multiracial identities: one as South Asian and White, and the other as Asian Pacific Islander and White. All but one of the 12 participants were from a middle-class background; one described growing up in a working-class family. Eight participants were residents of New Jersey or Pennsylvania at the time of data collection, while the other four were residents of New Mexico, Colorado, Texas, and Washington, D.C.
Data Collection
To be included in this study, participants had to be aged 18–25, view climate change as an important issue, have actively engaged in some form of environmental action for at least 6 months, reside in the United States, be able to communicate in English, and consent to participate in an audio-recorded interview lasting 60–90 minutes. Following IRB approval, we contacted key informants—academics in the climate movement who are recognized as leaders because of the reach of their speaking engagements and publications, and with whom we (Kathleen L. Grant and Melissa A. Alvaré) had a prior relationship—to recommend individuals who met the selection criteria. We also utilized social media platforms, including Facebook and Instagram, and posted an IRB-approved recruitment flyer on our personal and publicly accessible sites. Snowball sampling was used, as several respondents recommended their peers for interviews. Recruitment emails described the research study, detailed the interview procedures, and invited people to contact us if they were interested in participating. Once individuals responded to these emails, they were screened to see if they met the inclusion criteria. If so, they were asked to read and sign an informed consent document and complete a demographic questionnaire before scheduling the interview.
Interview questions were designed to elicit rich descriptions of participants’ lived experiences and perspectives. We utilized Arnett’s theory of emerging adulthood, specifically the five features of identity exploration, instability, self-focus, feeling in between, and possibilities/optimism, and considered how these factors would appear in climate awareness and action (Arnett, 2010, 2014). We drew from the existing literature to develop our initial interview guide, first drafting broad, open-ended domains. Then, we met to revise them with a critical eye, working to ensure that we were not asking leading questions or probes that were overly influenced by our own biases and expectations. Taking a phenomenological approach, we also ensured that our questions were crafted to go beyond eliciting descriptions to allow us to explore the meanings participants attached to phenomena of interest (e.g., climate change and career trajectories). We then sent a draft of our interview instrument to a renowned scholar in the field of climate justice, who made recommendations for further revisions.
All interviews were conducted and recorded over Zoom by one of the three authors. In line with the phenomenological tradition and our intentions to explore topics introduced by participants, we used semi-structured interviews. The semi-structured format promoted fluidity, allowing the informal dialogue to emerge and take unexpected directions, as respondents could discuss the topics most meaningful to them (Hesse-Biber & Leavy, 2010). The interview guide included questions such as: “How has learning about the environment impacted you personally, if at all?” “Has your environmental awareness had any impact on your life goals and/or career plans?” “When you think about the future, what feelings come up for you?” and “How, if at all, do you think you have changed as a result of your involvement in environmental action?”
We asked follow-up questions based on participants’ responses and probed—when appropriate—to gain clarity and delve deeper into their experiences and viewpoints. Interviews ranged from 55 to 75 minutes in length, and participants received $15 gift cards as compensation for their time and participation. The audio files from the recorded Zoom videos were sent to a professional transcription service.
Analysis
Given our hermeneutic phenomenological design, the analysis followed van Manen’s (1997) approach, which involves a cyclical process of reading, reflecting, and writing to uncover thematic structures. Researchers (a) turn to the nature of lived experience, (b) investigate experiences as lived, (c) engage in hermeneutic phenomenological reflection, (d) engage in hermeneutic phenomenological writing, (e) maintain a robust and oriented relation, and (f) balance the research while exploring the parts and whole (van Manen, 1997, pp. 30–31). As Starks and Trinidad (2007) wrote, in coding data from phenomenological inquiries, “specific statements are analyzed and categorized into clusters of meaning” with close attention to “descriptions of what was experienced as well as how it was experienced” (pp. 1375–1376). Transcripts were divided among us for an initial pre-coding of each interview. We each engaged in preliminary note-taking, marking repeated phrases and themes, and memo writing on potential codes and sub-codes during this stage. We then met to discuss initial interpretations of interviews, emergent themes, and perceptions of the powerful and insightful stories shared by participants. At that time, we also devised an initial inductive code and created a codebook and color scheme for the next coding round. We then re-divided the transcripts and each coded four transcripts in shared Microsoft Word documents. Once all 12 interviews were coded, we met again to discuss our analyses and refine and collapse codes. We repeated this process with each reading, using four new transcripts to examine our coding processes and contribute to our analyses with the new code list and interpretations of the data.
Trustworthiness
Our research team consisted of two counselor educators and one sociologist. We identify as White, middle and upper–middle-class women, aged 35–45, with shared concerns about the climate crisis. We engaged in ongoing discussions about how our social positions, interests, and privileges influenced all phases of the research process.
Trustworthiness was established primarily through prolonged engagement, critical reflexivity, and peer debriefing. We reviewed the audio recordings and transcripts for months. Both listening to the participants’ voices in the audio recordings of interviews and prolonged engagement with the transcripts is crucial for establishing trustworthiness, as it enables the researcher to see the world from each participant’s perspective and pick up on the richness and nuance of the narratives and ensures a thorough understanding of the participants’ statements, all of which are essential for phenomenological analyses (Moustakas, 1994). We were committed to maintaining an open stance and curiosity toward participants’ experiences. Each member of the team engaged in memo writing to document our emerging interpretations and consider how personal preconceptions and backgrounds might be influencing our interpretations. These memos were shared among the team and served as starting points for critical dialogue. We responded to each other’s memos, posing alternative perspectives and challenging probes to push one another to examine how personal biases might be shaping interpretations of the data. We also met regularly to engage in reflexive practice, unpacking the data collectively, scrutinizing our codes and emerging themes, seeking data that did not support the themes that were emerging, and interrogating how personal expectations and life experiences could be influencing our analyses. Whenever we found inconsistencies in our interpretations and/or data categorization schemes, we conducted thorough discussions to reach a consensus and ensure a uniform coding process.
Findings
This study aimed to gain a deeper understanding of the experiences of young adults engaged in environmental action during the transition from late adolescence to early adulthood. In particular, this study focused on the impact of environmental awareness and action on the participants’ development, personally and professionally, as they transition into adulthood. Through a hermeneutic phenomenological analysis of the 12 in-depth interviews, three key themes emerged from the participants’ narratives: 1) Fear for the Future, Anxiety, and Loss; 2) Limited Coping Strategies;
and 3) Tension Between Making a Difference and Making a Living.
Fear for the Future, Anxiety, and Loss
The environmentally aware participants expressed fear for the future, anxiety, and loss throughout their narratives. Most discussed pervasive anxiety and fear for the future related to the climate crisis. In contrast, other participants were triggered by specific situations, such as a severe weather-related event (locally or globally) or a climate change–related news item (i.e., the release of a UN report on the climate crisis). One participant, Theodora, also reflected on the present-day harm that communities are experiencing: “And it’s here right now, and increased natural disasters are not a future thing; they’re happening. . . . It’s definitely impacted my mental health.” Mary discussed how the climate crisis is causing a “collective trauma” in her generation. She said, “I think it’s really impacting everybody because individual action feels so futile. I think we’re just feeling really lost.” Many of the participants discussed a fear for their future as adults.
The participants specifically shared their fears about the future in light of the climate crisis. They raised questions about where they will live, whether they should have children, and the state of the planet. Brianna stated that it is a “daunting and terrifying idea, if we don’t start to get it [global warming] worked out, just how much of an impact it can have on our future.” Amy stated, “I could say that the climate crisis has negatively impacted mental health . . . [I experience] anxiety and worry about the state of the planet, now and in the future.” Briana described:
It’s pretty hard to feel hopeful, especially since all of us live here in Colorado now, where fires are a big problem and stuff like that. We often have conversations where we’re like, “So the West is going to be on fire, and the Southwest won’t have water, and the coastlines are going to be flooded. Where can we live?”
Three participants (25%) discussed, without specific prompting, whether or not to have a child, as the climate crisis would profoundly impact their child’s life. Nancy stated, “I feel like my generation . . . is not the biggest about having kids. . . . There’s not going to be a good place for us to live.”
Several participants used the terms eco-anxiety and climate grief to discuss their emotional experiences related to climate change. Nancy indicated that reports of natural disasters trigger her eco-anxiety, and Carol stated that she started psychiatric medication partly because of her eco-anxiety. Evan discussed his feelings of climate grief, helplessness, and powerlessness.
Limited Coping Strategies
The participants discussed various coping strategies for dealing with their intense climate-related emotions. The main strategies were adopting a positive mindset and ignoring or withdrawing from climate information/action. These two strategies are discussed below, after which the remaining strategies are briefly discussed.
The majority of the participants discussed choosing to stay optimistic about the future as a coping strategy. They discussed thinking about all the people, including themselves, who are engaged in climate action to make a difference. Alex discussed guarding against negative feelings by avoiding getting “too down on myself” or adopting “too negative of an outlook” and engaging in individual action as a coping strategy. Participants elaborated on the challenges they faced in maintaining a positive perspective, especially as they age and see an increasing number of negative climate-related events. Jackson stated that it is “more and more of a struggle” to maintain a positive attitude and be motivated to take climate action.
Participants also shared examples of ignoring or withdrawing from climate-related information or action as a means of coping with negative feelings or protecting themselves. Daniel stated, “I have taken an approach of doing the most that I can in my community while choosing to stay a little ignorant on what’s happening globally.” Sarina shared, “I felt pretty stressed and sort of want . . . to give up on trying to help environmental problems because a lot of them are so far gone that it can be pretty discouraging to read about.” Mary elaborated on her emotional experience:
And it almost teaches you, I’ve found, not to feel your feelings. So in a sense, I find myself becoming more apathetic because you’re desensitized to it. You’re seeing it all the time, but you can’t feel it all the time because no one wants to stare into the impending doom of environmental decay or whatever.
Three of the participants discussed connecting with their community as a means to address their fears and concerns about the climate crisis. All three of these participants reported connecting with others who are environmentally minded or engaged in climate action. One participant discussed therapy as a strategy: “I do see a therapist occasionally. . . . She’s not trained on the eco-side of things. So she tries to understand and gets tools and whatnot, but definitely, it’s not her main area of concern. But she’s been helpful anyways.”
Two participants discussed being in nature, specifically hiking, as a coping mechanism. Mary stated, “Life outside and living a life that is environmentally based actually brings me a lot of joy, and that component of it doesn’t stress me out and give me anxiety.” Sarina shared that she does not have a clear coping strategy:
So even though me and my friends . . . are people who are trying to work towards improving things, I would say we all can feel pretty hopeless about the situation, especially [when] the current government-level response is not very strong. . . . I want to be hopeful, but I would say from a scientific perspective, it can also be pretty hard to feel hopeful for the future. Yeah, I don’t really have an answer. . . . it can be pretty overwhelming, and you just kind of have to try to think about something else. Because I guess I can remind myself I’m already working to try to increase knowledge, and that’s useful. So, I guess I’m playing some positive part, and so I can try to relieve myself with that information. But yeah, I guess I don’t really have a good way to feel better about it.
Tension Between Making a Difference and Making a Living
The participants in this study were all in a transition period between adolescence and adulthood. In their narratives, many of the participants (n = 7) expressed the tensions between their environmentally based values and the need for a job that would provide economic security. These tensions emerged as the participants struggled to make choices congruent with their stated values and career choices that might have long-term impacts, both individually and for their communities.
The role of money and financial stability was not directly probed for in the interview protocol; however, participants often brought it up when asked what prevents them from engaging in environmental action. Jackson stated, “You can either pursue this as a passion and as an ideal and as a thing to do, or you can . . . make money and have a stable life.” He went on to state:
And so I grew up with a lot of that type of thinking, of like, eventually, you’re going to have to kind of settle your own goals and ideals in order to survive in the world on your own and provide safety nets to your family later on. And so I always kind of grew with that . . . in the back of my mind, and that became more present in college. . . . I think those have been the biggest kind of like detractors . . . like “You have to choose one or the other.” Like, they [parents] weren’t necessarily discouraging my passion or any of that, they were just kind of like, “It’s one or the other.” Most people fall for the latter, and that’s kind of why we have the issues in the first place.
Evan discussed grappling with either getting paid with a traditional job or engaging in more meaningful environmental activism on a volunteer basis. He shared:
I guess, unfortunately, money is a factor. I found more ways to get paid for teaching than for volunteering my time. You have to think about, “What’s the balance of that going to be?” I need to be able to support myself, and so when I can, I will dedicate time to being active in my community and engaging with environmental issues. So, finding a balance.
Brianna, who was in law school studying environmental law, discussed the tension as she sees it:
Society . . . pins people against environmental work because it’s not lucrative, or they paint it not to be lucrative because I think people can make a decent living and know that they’re doing something beneficial. But I would say that there’s still a stigma in society just surrounding environmental work, and that if you want to make money and you want to live decently, that’s not the field to go into. I fully don’t believe in that anymore, but I think that that played a role in my choices.
Although most participants indicated that financially providing for themselves was a significant detractor from an environmentally focused career, several participants had alternative narratives. Amy, an environmental educator at a nonprofit land trust, discussed the importance of taking time in college to discover her identity and selecting a career aligned with her values, even if it was not financially lucrative. However, her financial realities were still infused into her thinking, reflected by her parents’ repeated refrain: “My parents, from day one, always said, ‘Pursue your passion, do what you love, and the money will come.’” Other participants were exploring careers in academia and research as methods to bring about change and did not mention finances as an impediment to an environmentally oriented career.
Discussion
This study aimed to gain insight into the lived experiences of environmentally aware individuals as they transition from adolescence into adulthood. Specifically, Arnett’s developmental theory of emerging adulthood was utilized to frame these experiences, as it considers the dynamic interactions among experiences, emotions, and actions within this critical developmental period between adolescence and adulthood (Arnett, 2000). In particular, Arnett’s theory provides insight into the tension and instability that young adults experience during this transition, particularly in terms of identity, career, and emotional development.
Three main themes emerged from the participants’ narratives, including feelings of fear for the future, anxiety, and loss; limited coping strategies; and tension between making a living and making a difference. Each participant described fear for the future, anxiety, and loss. These findings align with past research exploring mental health concerning the climate crisis (Gislason et al., 2021; Hickman et al., 2021; Ojala et al., 2021; Sanson et al., 2019). The depth and breadth of the participants’ descriptions of fear and anxiety suggest that thoughts, feelings, and experiences around the climate crisis impact their daily lives. Some participants reported powerful emotional responses to negative news about the climate. They were pondering significant life choices because of the climate crisis (e.g., questions about where to live and whether to have children). As previous researchers have suggested, these responses appear appropriate given the realities of the climate crisis and the expected impact it will have on their lives and those of future generations (Hickman et al., 2021). However, although participants expressed and communicated these fears and anxieties, few seemed to have comprehensive structures (psychological, behavioral, or relational) to act on their pervasive and legitimate concerns. Participants often managed complex feelings and plans independently in the absence of communities informed about their fears and realities for the future, which could help them navigate the challenges and possibilities of a life and a future heavily impacted by the climate crisis.
Although all participants experienced a range of emotional reactions to the climate crisis, they also employed various strategies to manage their feelings. The participants generally appeared to have limited strategies for dealing with challenging climate-related feelings. Most of the strategies were individualistic, and young people had to figure out how to manage their deep and complex emotions independently. Several participants discussed being optimistic as a coping strategy but also voiced that this strategy is ineffective and exhausting. Although keeping a positive attitude in the face of adversity can be beneficial, doing so without acknowledging or feeling the vast array of emotions associated with the climate crisis and their fear for their futures may be ineffective. This finding aligns with the conclusions of Hickman et al. (2021), which demonstrate that young people are facing unique stressors arising from the climate crisis that can impact their development.
Several participants discussed ignoring aspects of the climate crisis or the climate crisis itself to protect themselves. Denial is a common psychological defense to reduce climate-related distress (Doherty & Clayton, 2011). Participants noted that they disengaged from environmental action to avoid challenging feelings related to climate change. These individuals may benefit from positive strategies to manage their emotions, allowing them to take care of themselves and continue to be active citizens working toward change. Finally, participants shared coping strategies, including spending time in nature and engaging in therapy, as strategies to support their mental health. Participants also engaged with environmental communities as a coping strategy, which can be a significant influence during such a developmental period. Social and cultural factors have been shown to influence young people during the development of emerging adulthood as they crystallize their identities and career paths (Arnett, 2010). As the future will include increasingly complex and challenging climate crisis–related issues, individuals in this study may benefit from additional coping strategies, which will be further discussed in the Implications for Counseling section.
The final theme illuminated by the participants is the tension between making a difference and making a living. Participants discussed the challenges inherent in creating environmental change, often in low-paying or volunteer capacities, and the desire to support themselves financially. Although the participants were interested in environmental action, both professionally and personally, they often struggled to create a life in adulthood where they could enact their values. Participants described examples of their engagement in environmental causes in high school and college but had a more challenging time maintaining action as they transitioned to adulthood. Although part of the challenge seemed to be the lack of clear, viable paths for the participants to engage in environmental action and careers as adults, financial realities also shaped their choices. Participants viewed jobs in the environmental sector as less lucrative than others, and they would not be able to support themselves or their future families on this salary, especially if they wished to maintain the same socioeconomic level as they were offered. Additionally, the participants saw this tension as a dichotomy; they could either have a well-paying career or engage in environmental action.
Implications for Counseling
Young adults are increasingly experiencing mental health impacts of the climate crisis (Hickman et al., 2021). This study offers insight into the developmental and emotional experiences of young adult participants as they navigate the transition to adulthood, exploring how to make sense of their environmental concerns and act to create change. Counselors, including school counselors, college counselors, career counselors, and clinical mental health counselors, can play a crucial role in supporting mental health and wellness in the context of the climate crisis. Both the National Board for Certified Counselors (NBCC; 2025) and the American Counseling Association (ACA; Sturm et al., 2020) have issued statements emphasizing the need for counselors to advocate for climate action and educate themselves and others on the mental health implications of climate change.
The findings of the current study support the need for counseling services because of climate change impacts on mental health. Findings reveal that participants were experiencing challenging emotions related to the climate crisis and had limited strategies to cope with the changing world. Three implications for counseling are discussed below: increasing counselors’ climate change mental health literacy, supporting resilience, and the ethical responsibility of counselors as advocates.
Recommendation 1: Increase Counselors’ Climate Change Mental Health Literacy
Counselors must practice “within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience” (ACA, 2014, Section C.2.a.). Many counselor education training programs do not cover the unique experiences and challenges individuals face because of the climate crisis, resulting in a void in counselor education training (Heiman, 2024; Hilert, 2021). Therefore, to ethically assist clients with this need, counselors must continue their education and, where necessary, seek additional supervision to treat this population. As a first step, counselors can consider learning more about the nature of the climate crisis, including the impacts on future generations (Doherty & Clayton, 2011). Publications such as the American Psychological Association’s 2021 report, Mental Health and Our Changing Climate: Impacts, Inequities, and Responses (Clayton et al., 2021), provide a comprehensive overview of the nature of the climate crisis and strategies for mental health practitioners. Counselors can also seek support, training, and consultation through membership in the Climate Psychology Alliance of North America, a community of mental health professionals who educate climate-aware practitioners (https://www.climatepsychology.us).
Participants in this study noted that their mental health practitioners were not adept at addressing their climate anxiety and trauma in sessions. Individuals may not directly broach the topics of climate anxiety, eco-grief, and weather-related PTSD; therefore, counselors must address these topics directly with clients. Climate-aware counselors must facilitate the expression of clients’ emotions about the climate crisis and help them further explore and articulate their experiences (Doherty & Clayton, 2011). Counselors can consider using interventions that facilitate emotional expression and create opportunities for adaptive behaviors (Doherty & Clayton, 2011). Interventions can also include existential therapy, particularly exploring how to find meaning, peace, joy, and hope in the face of ecological collapse and climate-related disasters (Barry, 2022; Frankl, 2006). Finally, eco-therapy is a promising modality for clients that centers healing through nurturing a stronger relationship with nature and the physical environment (Delaney, 2019). As such, it is recommended that counselors expand their knowledge of the climate crisis and its impact on mental health to serve their clients better as well as any supervisees.
Recommendation 2: Supporting Young Adult and Client Resilience
This study found that participants lacked comprehensive structures to address their climate anxiety and fears about the future. Many participants felt overwhelmed by the climate crisis, which impacted their ability to take action in the climate movement. As a coping strategy to protect themselves from difficult feelings associated with climate change, some participants withdrew from climate information or action. As challenging weather-related events and the impact of the climate crisis are expected to increase in the coming years, young adults must develop both internal and external resources to survive and thrive in a changing world (Gislason et al., 2021).
Fostering resilience is an effective strategy for supporting the mental health and well-being of young adults, including those affected by the climate crisis (Clayton et al., 2021). Resilience can be fostered through the development of both internal and external resources, and counselors can play a crucial role in this process. Internal resources can include increasing self-efficacy or young adults’ belief in their ability to overcome the stress and trauma associated with climate change. Research suggests that those who believe in their ability to withstand the challenges associated with climate change have more positive psychological outcomes than those with lower self-efficacy (Clayton et al., 2021). Belief in one’s resilience is also correlated with fewer symptoms of depression and PTSD after natural disasters (Ogunbode et al., 2019).
Counselors can support young adults in developing external resources that enhance resilience, such as fostering social connections. Social connections to peers and those of different generations can be a vital source of emotional, informational, logistical, and spiritual support (Center for the Study of Social Policy, 2019). Individuals’ ability to withstand trauma and adversity increases when they are connected to strong social networks (Clayton et al., 2021).
Finally, this study found that participants did not have clear paths to enact their environmental values in their adult lives. They faced financial and cultural pressures to choose careers that would allow them to make a living. Although this study highlights that some participants may not have had the internal and external resources to cope with the emotional stressors of engaging in climate-related work, a viable career or civic path was elusive. All counselors who work with young adults, especially school and career counselors, have the opportunity to provide resources about the wide array of jobs available in the green economy, as well as methods to include civic involvement (i.e., participation on local environmental commissions, participation in activist groups, leadership in local government advocating for green policies) when planning one’s adult life. Models of adults who engage in environmental action, both personally and professionally, must be provided to young people as examples of possible paths in adulthood. As taking action is seen to have numerous mental health benefits, specifically as it builds agency, counselors must support clients in developing the attitudes, skills, and behaviors necessary to engage in activism and advocacy (Gislason et al., 2021; Sanson et al., 2019).
Recommendation 3: Ethical Responsibility of Counselors as Climate Advocates
Counselors are ethically responsible for advocating for the well-being of their clients, as stated in the ACA Code of Ethics (2014): “When appropriate, counselors advocate at individual, group, institutional, and societal levels to address potential barriers and obstacles that inhibit access and/or the growth and development of clients” (Section A.7.a.). The climate crisis is and will continue to significantly negatively impact the growth and development of clients, with young clients and clients from historically marginalized populations such as people of color and people with low incomes among the most vulnerable (IPCC, 2023; Watts et al., 2015). Counselors’ ethical responsibility is to advocate for local, state, and national policies and practices to prevent the most dire climate outcomes and support a livable future for all. This includes the counseling profession’s call for counselors to be active in policy initiatives and advocacy related to climate change (NBCC, 2025). Such policies may consist of those that support a just transition away from fossil fuels and to renewable sources of energy; agricultural strategies that reduce emissions, shift toward more sustainable diets, and reduce food waste (United Nations Environment Programme, 2020); and nature-based solutions such as stopping deforestation and ecological degradation and moving toward ecosystem regeneration (United Nations Environment Programme, 2020). As the impacts of the climate crisis are felt most significantly in communities of color (who are more likely to be situated in floodplains, heat islands, downwind from fossil fuel-burning plants, etc.), there is an added ethical responsibility to advocate for the well-being of the most vulnerable.
Limitations and Future Research
This study had several limitations. First, the majority of participants identified as White and middle class. The study would have benefited from a greater diversity of participants to gain a broader perspective on cultural differences as they relate to the experiences of climate change, development, and mental health. Additional research is necessary to gain insight into the experiences of young adults across the intersections of identity, specifically focusing on those who will suffer the greatest impacts of the climate crisis, such as individuals from the global majority and low-income households. Secondly, all participants in this study were currently or had been previously engaged in some level of environmental action. The results of this study may not be applicable to those who are concerned about climate change but not actively engaged in taking action. Finally, although a sample size of 12 was suitable for the goals of this research and the standards of hermeneutic phenomenology (van Manen, 1997), the nature of qualitative research limits the ability to generalize these findings.
The participants in this study struggled with diverging from the status quo to make choices aligned with their values. In particular, values associated with individualism and capitalism frequently appeared as roadblocks, such as pressure to make a certain financial living and engaging with problems and solutions from an individualistic perspective. More research is needed to understand how young people challenge and resist dominant cultural values that prevent them from taking action to bring about environmental change and may contribute to poor mental health outcomes.
Conclusion
This study sheds light on the lived experiences of environmentally aware young people. Commensurate with previous findings, participants expressed fear for the future, anxiety, and loss (Hickman et al., 2021). This study highlighted the limited comprehensive strategies available to young people for addressing their climate-related emotions, which affected their ability to remain engaged in climate action. Additionally, participants felt significant cultural and financial pressure to make a living, which stood in contrast to their ability to engage in personal or professional environmental action. Counselors can support young adults by enhancing their climate-related mental health literacy, offering climate-specific interventions to increase their resilience, and engaging in social change through advocacy.
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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Kathleen L. Grant, PhD, NCC, is an associate professor at The College of New Jersey. Alyson Pompeo-Fargnoli, PhD, NCC, LPC, is an associate professor at Monmouth University. Melissa A. Alvaré, PhD, is a lecturer at Monmouth University. Correspondence may be addressed to Kathleen L. Grant, 2000 Pennington Rd, Ewing Township, NJ 08618, grant24@tcnj.edu.
Aug 26, 2025 | Volume 15 - Issue 3
Julie C. Hill, Toni Saia, Marcus Weathers, Jr.
Ableism is often neglected in conversations about oppression and intersectionality within counselor education programs. It is vital to expand our understanding of disability as a social construct shaped by power and oppression, not a medical issue defined by diagnosis. This article is a call to action to combat ableism in counselor education. Actionable recommendations include: (a) encouraging professionals to define and discuss ableism; (b) including disability representation in course materials; (c) engaging in conversations about disability with students; (d) collaborating with, responding to, and supporting disabled people and communities; and (e) reflecting on personal biases to help dismantle ableism within counselor education. Implications for counselor educators highlight the ongoing need for more ableism content within the profession.
Keywords: ableism, disability, counselor education, representation, biases
Disability is rarely examined through intersectionality and critical consciousness, despite its deep connections to race, class, gender, and other social identities (Berne et al., 2018). As the United States becomes increasingly diverse, the need for counselors who can competently address the complex, intersecting needs of disabled people has never been more urgent (Dollarhide et al., 2020). Disabled people are the largest and fastest-growing minority group, with approximately 60 million people reporting some form of disability (Elflein, 2024). Despite this increasing prevalence, ableism, known as the systemic discrimination and exclusion of disabled people, remains persistent in our society. Slesaransky-Poe and García (2014) further discuss ableism as the belief that disability makes someone less deserving of many things, including respect, education, and access within the community.
Ableism and ableist beliefs have profoundly shaped how society perceives and interprets the disability experience. Historically, the medical model has framed disability as an inherent defect within the individual, requiring treatment, rehabilitation, or correction to restore “normal” functioning (Leonardi et al., 2006). This deficit-based perspective, reinforced by legal definitions, has shaped societal attitudes and policies, often prioritizing intervention over community integration. In contrast, the social model of disability shifts the focus from the individual to the broader societal structures, emphasizing how inaccessible environments, exclusionary policies, and ableist attitudes create disabling conditions (Bunbury, 2019; Friedman & Owen, 2017; Shakespeare, 2006). This model asserts that disability is not simply a medical issue, but a social justice concern requiring systemic change to remove barriers and promote full participation. Within counselor education programs, the biopsychosocial model is often taught as a more integrative framework that acknowledges disability as a complex interplay of biological, psychological, and social factors. Although medical interventions may be necessary for some individuals, this model emphasizes addressing environmental and attitudinal barriers contributing to marginalization. By adopting this holistic approach, counselors can better advocate for equity, inclusion, and meaningful accessibility for all.
This article provides an asset-based framework that views disability as a valuable aspect of diversity rather than a deficit or limitation. This approach recognizes the strengths, perspectives, and contributions that disabled people bring to communities and educational spaces (Olkin, 2002; Perrin, 2019). By embracing disability as an aspect of diversity, this framework challenges societal norms rooted in ableism, which often prioritize conformity and cure over anti-ableism (Bogart & Dunn, 2019). Through this lens of power and oppression, disability is celebrated as a source of innovation, creativity, and cultural richness, encouraging practices that empower disabled individuals to thrive both in the classroom and in the community. To reinforce this shift in thinking to disability as an asset, we use identity-first language, recognizing that many disabled people prefer it as a positive affirmation of their lived experiences and their connection to the disability community (Sharif et al., 2022; Taboas et al., 2023).
Intersectionality and Disability
Scholars recognize intersectionality as an analytical tool to investigate how multiple systems of oppression interact with an individual’s social identities, creating complex social inequities and unique experiences of oppression and privilege for individuals with multiple marginalized identities (Collins & Bilge, 2020; Crenshaw, 1989; Grzanka, 2020; Moradi & Grzanka, 2017; Shin et al., 2017). The topic of disability is often absent in conversations regarding power, oppression, and privilege (Ben-Moshe & Magaña, 2014; Erevelles & Minear, 2010; Frederick & Shifrer, 2018; Mueller et al., 2019; Wolbring & Nasir, 2024) despite the potential for disability to intersect with other marginalized identities (e.g., racial/ethnic identity, gender identity, socioeconomic status, religious and spiritual beliefs, citizenship/immigration status) that lead to intersectionality-based challenges that conflict with the marginalization of being disabled (Wolbring & Nasir, 2024). For example, Lewis and Brown (2018) condemned the lack of accountability in reporting on disability, race, and police violence, which often irresponsibly neglects the coexistence of disability in conversations of experienced violence. Using the framework of intersectionality responsibly in disability discourse within counselor education holds significant potential for the professional development of counselors to work toward unmasking and dismantling ableism.
Challenges and Gaps in Anti-Ableism in Counselor Education and Training
How counselor educators teach about disability is crucial to dismantling ableism, yet history reveals a troubling lack of cultural humility in educational approaches. Cultural humility is a process-oriented approach that continuously emphasizes the counselor’s openness to learn about a client’s culture and invites counselors to consistently incorporate self-reflective activities to enhance their self-awareness (Mosher et al., 2017). Although cultural humility may be well intended, it may also have a harmful impact and fall flat if inherent biases go unrecognized. For example, counselor educators heavily relied on simulation exercises to address disability in the classroom (e.g., having students blindfold themselves for an activity to simulate blindness or having them sit in a wheelchair for a short period). Simulation exercises reinforce a deeply medicalized and reductive view of disability, one rooted in fear, pity, and misconception, ultimately erasing disability as both a culture and an identity (Öksüz & Brubaker, 2020; Shakespeare & Kleine, 2013). Beatrice Wright (1980, as cited in Herbert, 2000), cautioned that simulation experiences evoke fear, aversion, and guilt. These exercises rarely foster meaningful or constructive perspectives on disability. Instead of deepening understanding, these exercises risk reinforcing harmful stereotypes, further marginalizing disabled individuals rather than empowering them. Instead of disability simulations, honor the voices and experiences of disabled individuals through their narratives, such as Being Heumann by Judy Heumann, as well as documentaries and movies like Crip Camp, Patrice, or CODA. Contact with disabled individuals has been shown to reduce stigma against disabled people (Feldner et al., 2022; Smith et al., 2011). Additionally, incorporate analyzing ableism through case studies, readings, or media, followed by a structured discussion.
Topics of multiculturalism and diversity have increased over the years; the same cannot be said for disability (Rivas, 2020). Davis (2011) poignantly asked, “Is this simply neglect, or is there something inherent in the way diversity is considered that makes it impossible to recognize disability as a valid human identity?” (p. 4). More than a decade later, this question remains painfully relevant. Atkins et al. (2023) explored this issue through a study using the Counseling Clients with Disabilities Scale to evaluate professionals’ attitudes, competencies, and preparedness when working with disabled clients. The findings underscore the critical need for education and exposure to disability-related topics in counselor training, demonstrating that such efforts improve competency, reduce biases, and foster more inclusive, equitable, and empowering support. However, disability continues to receive significantly less attention than other cultural and identity groups in professional training and discourse (Deroche et al., 2020).
Furthermore, ableist microaggressions continue to be a concern for disabled individuals. Cook and colleagues (2024) conducted a study looking at microaggressions experienced by disabled individuals and found four categories of microaggressions: minimization, denial of personhood, otherization, and helplessness. They also found that experiencing ableist microaggressions affected participants’ mental health and wellness. Additionally, they found that those with visible disabilities were more likely to experience ableist microaggressions than those with invisible disabilities. Given these findings, counselor educators need to be aware that ableist microaggressions exist, what those microaggressions may sound like, and how they impact disabled clients.
Concerns exist about the extent to which counselor education programs cover disability content; there is also a need to examine instructors’ preparedness for covering such content. In a survey of counselor educators in programs accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP), 36% of the faculty surveyed believed their program was ineffective at addressing disability topics and that programs did not address disability and ableism to the extent necessary to produce competent professionals. Only 10.6% felt their program to be “very effective” in this content area, with the belief that their students were only somewhat prepared to work with disabled people (Feather & Carlson, 2019). Notably, these oversights in education translate into inadequacy in practice. A sample of mental health professionals who all reported working with disabled clients indicated the least amount of perceived disability competence in skills, the second least competence in knowledge, and the most competence in awareness (Strike et al., 2004). Faculty self-assessment of their ability to teach disability-related content was strongly linked to their prior work or personal experience with disability. This highlights the importance of integrating exposure to and training on disability-related concepts throughout core areas (Pierce, 2024). Although separated by a decade, these studies can be tied to a unifying, persistent issue: the lack of disability competence in counseling and counselor education spaces.
The 2024 CACREP standards call for an infusion of disability competencies into counseling curricula (CACREP, 2023), meaning that counselor educators and counselors-in-training must reimagine the available literature to provide adequate professional development and growth. Pierce (2024) advised that disability competence areas be focused on the following topics: accessibility, able privilege, disability culture, and disability justice. We must seek to dismantle ableism by infusing disability into curricula in an authentic manner that highlights the societal values and attitudes in which multiple forms of oppression work in tandem to create unique, intersectional experiences for disabled people.
Training Recommendations for Counselor Education Programs
The authors aim to ensure counselor educators have tangible strategies to dismantle ableism and teach their students to do the same. Counselor educators and counselors-in-training must look inward and rid themselves of negative attitudes and biases to eradicate ableism. Part of this process includes the critical skill of self-reflection and examining and understanding biased and ableist beliefs held by individuals and perpetuated by society. Until that happens, counselors will continue to do a disservice to disabled people (Friedman, 2023). For students who have never interacted with disabled people or thought about ableism, these conversations and strategies have the very real possibility of making them uncomfortable. Discomfort is okay. Disabled people often feel awkward or out of place every day because of ableism. It is not our job as counselor educators to make students comfortable; it is our job to make them competent, informed, and ethical professionals.
The following are five tangible strategies to thoughtfully and intentionally dismantle ableism. These strategies are purposefully broad and aim to expose counseling professionals and those in training to an intersectional perspective of disability that acknowledges disability as a valid aspect of diversity, identity, and culture. Rather than siloing these discussions to disability-related training, these strategies belong in all settings within counseling. Counseling professionals must include ableism in the conversations happening in places where they learn and work to shift the way they think, view, respond to, and construct disability. To begin, counselor education programs should consider hosting a workshop or seminar focused on ableism by disabled people to ensure that all students and faculty are on the same page and are using the same terminology. Once this has been established, ableism and disability content and knowledge should be incorporated into lectures, assignments, discussions, and exams across the counselor education curriculum. Further information on this integration is described in the first strategy below.
Define Ableism
One of the factors that further perpetuates ableism is the lack of clarity on what ableism is and how it intersects with other forms of oppression. Counselor educators must share definitions of ableism that center on the perspective of the disabled community. Talia Lewis (2022) provided a working definition of ableism that disabled Black/negatively racialized communities developed:
A system of assigning value to people’s bodies and minds based on societally constructed ideas of normalcy, productivity, desirability, intelligence, excellence, and fitness. These constructed ideas are deeply rooted in eugenics, anti-Blackness, misogyny, colonialism, imperialism, and capitalism. This systemic oppression leads to people and society determining people’s value based on their culture, age, language, appearance, religion, birth or living place, “health/wellness,” and/or their ability to satisfactorily re/produce, “excel,” and “behave.” You do not have to be disabled to experience ableism. (para. 4–6)
This definition expands on the definition provided earlier of ableism as the systemic discrimination and exclusion of disabled people. It rejects the notion that ableism can be dismantled or separated from other forms of oppression (e.g., racism, sexism, and other systems of oppression). Within counseling curricula, we often use the term intersectionality, but it is impossible to address intersectionality with our students if we do not thoughtfully include ableism. We should challenge the idea that disability is a monolithic experience as we seek to build a more complex, interconnected, and whole understanding of disability (Mingus, 2011).
It is also essential to acknowledge internalized ableism, which is ableism directed inward when a disabled person consciously or unconsciously believes in the harmful messages they hear about disability. They project negative feelings onto themselves. They start to believe and internalize the message that society labels disability as inferior. They begin to accept the stereotypes. Internalized ableism occurs when individuals are so heavily influenced by stereotypes, misconceptions, and discrimination against disabled people that they start to think that their disabilities make them inferior (Presutti, 2021). For example, a disabled student may not participate in class because they believe their contributions are inferior compared to their nondisabled peers, or a disabled client may experience feeling undeserving, undesirable, and burdensome.
To effectively implement this awareness, ask students to define ableism in their own words. Coming up with their definition of ableism encourages critical thinking and allows the counselor educator to gauge students’ existing understanding. Then, introduce the Lewis (2022) definitions above to provide a more comprehensive framework. To reinforce these concepts, incorporate case studies illustrating real-world examples of ableism. Analyzing these cases in class discussions or group activities will help students identify ableist structures, challenge assumptions, and explore solutions for creating more welcoming environments. Counselors can examine ableism in societal contexts by viewing movies or television shows that feature disabled characters and analyzing how ableism is portrayed in media. Because of societal barriers to access and the taboos surrounding discussions of disability, the entertainment and news media serve as a key source for many people to form opinions about disability and disabled individuals. Unfortunately, these portrayals are limited and often spread misinformation and harmful stereotypes (Pierce, 2024). One way to help combat this could be by watching a movie or show together as a class and then having a discussion or having students watch on their own and write a short reflection followed by a class discussion. Some suggested movies include Crip Camp, Murderball, The Temple Grandin Story, Patrice, and Out of My Mind. Some suggested television shows include Speechless, Love on the Spectrum, Special, Raising Dion, Atypical, and The Healing Powers of Dude.
Include Disability Representation in Course Content
The phrase “representation matters” also applies to disability. Counselor educators should include disability and discussions of the impact of systemic ableism throughout course content, not only in a single lecture or reading on the course syllabus. Decisions about course content send powerful messages about what the counselor educator, the program, and the broader counseling profession prioritize and value. Including or excluding specific topics reflects the educator’s perspective and shapes future counselors’ professional identity and competencies. When disability is overlooked or inadequately addressed, it signals to students that it is not a central concern in counseling practice, which reinforces systemic gaps in knowledge, awareness, and advocacy. To counter this erasure and to ensure meaningful representation, intentionally incorporate guest speakers, videos, readings, memoirs, and research that center on the perspectives of disabled people. This gives students an authentic and multifaceted understanding of disability beyond theoretical discussions. Consider integrating a book or memoir that centers a disabled perspective alongside the course textbook to bridge the gap between academic content and real-life experiences. This approach not only deepens students’ engagement but also challenges ableist assumptions by highlighting the lived realities, resilience, and contributions of disabled people.
Engage in Conversation About Disability With Students
Disability is not a bad word. Counselor educators must instill this simple yet profound truth in students. Euphemisms like differently abled, handicapable, or special needs perpetuate ableism when used in place of the term disability, implying that disability is something shameful or in need of softening; they do more harm than good. Counselor educators must allow students the opportunity to engage in discussion about disability to challenge the idea that disability is taboo and move into a space where students can appreciate that disability is a natural part of life. Counselor educators must foster a safe and supportive learning community that allows students to engage in dialogue and discussion about their beliefs and experiences that have shaped their beliefs, and examine how those beliefs led to the development or perpetuation of ableist ideas and microaggressions. This allows students to learn, grow, and reshape their beliefs and understanding together. This quote sums it up best: “Disabled people are reclaiming our identities, our community, and our pride. We will no longer accept euphemisms that fracture our sense of unity as a culture: #SaytheWord” (Andrews et al., 2019, p. 6). To empower students to #SayTheWord in both classroom discussions and professional practice, dedicate time, especially during the first weeks of class, to explicitly affirm that disability is not a bad word. Normalize its use by providing historical context, sharing first-person perspectives, and emphasizing the importance of language in shaping attitudes. By reinforcing disability as an act of recognition rather than avoidance, you help students develop confidence in using identity-affirming language and challenging the stigma often associated with the term.
Collaborate, Respond, and Support Disabled People
Counselor educators, counselors, and counselors-in-training should seek opportunities to listen to, respond to, support, and collaborate with disabled counselors and other disabled scholars. Thoughtful collaborations allow for authentic exposure and conversation that support the unlearning of ableist beliefs. This approach is consistent with the disability rights mantra “nothing about us without us” (Charlton, 1998, p. 3), which implies that no change can occur without the direct input of disabled individuals. One opportunity for collaboration includes professional conferences and attending presentations by disabled academics and professionals. Other opportunities for collaboration include working with and supporting local disabled business owners and seeking out organizations such as independent living centers to bring in disabled speakers to share their lived experience and interactions with ableism and microaggressions. Be sure to compensate these individuals for their time so that the work of collaboration is mutually beneficial to all parties.
Disabled people are the experts of their experiences, not professionals. This statement is not synonymous with implementing a client-centered or person-centered approach. Instead, the focus of this statement is to make sure counselors have the tools to trust, support, uplift, and dismantle ableism with disabled clients. If it starts in the classroom, counselors-in-training will be better prepared in practice and life outside of work. As professionals know, trust in the counselor-client relationship is essential for the disabled community. It often develops when individuals feel heard, trusted, and validated, rather than being second-guessed or minimized, especially as they share about the external and internal ableism they face daily. Lund (2022) recommended consulting with both disabled psychologists and trainees to bring a “critical insider-professional perspective” (p. 582) to the profession. By consulting and bringing these disabled professionals in for training or speaking about personal experiences, we can ensure that disabled voices are heard and recognized.
Another way to amplify disabled voices is through the teaching of disability justice. The Disability Justice framework affirms that every person’s body holds inherent value, power, and uniqueness. It recognizes that identity is shaped by the interconnected influences of ability, race, gender, sexuality, class, nationality, religion, and other factors. It stresses the importance of viewing these influences together rather than separately. From this perspective, the fight for a just society must be grounded in these intertwined identities while also acknowledging Berne et al.’s (2018) critical insight that the current global system is “incompatible with life” (para. 13). Central principles of disability justice, such as centering leadership by those most impacted, fostering interdependence, ensuring collective access, building cross-disability solidarity, and pursuing collective liberation, prioritize intersectionality and cross-movement collaboration to guarantee that no one is excluded or left behind. (Pierce, 2024).
Helping students understand and internalize these ideas and principles should lead to the development of more aware and anti-ableist counselors in several ways. Rather than viewing client struggles as isolated or purely personal issues, understand that many forms of suffering, especially those faced by disabled people and people with intersecting marginalized identities, are rooted in larger social, economic, and political systems that devalue certain lives. For example, ableism, racism, and capitalism often create conditions that threaten people’s survival, whether through limited access to health care, environmental injustice, or social exclusion.
Counselors-in-training should be attuned to how multiple aspects of identity (such as disability, race, gender, and class) interact to shape each client’s lived experience. This approach moves counseling away from a one-size-fits-all perspective and helps address the unique, layered barriers that clients face. Traditional counseling and counselor preparation often focus on assisting clients to adapt to oppressive systems. The Disability Justice perspective instead calls for counselors-in-training to see their role as also advocating for systemic change, working toward environments and policies that are actually supportive of all people’s well-being. Rather than idealizing independence, disability justice values interdependence and community care. Counselors and counselors-in-training can foster this by helping clients build supportive networks and by modeling collaborative, relational approaches in practice.
Regularly Reflect on Personal Biases and Be Open to Feedback
Counselor educators often ask counselors-in-training to reflect on their own biases in terms of race, gender, and sexual orientation. However, ableism and disability are often forgotten or left out of those conversations. It is essential for these conversations about bias to include disability so that everyone has opportunities to explore and discuss their own potential biases. Embedding disability representation in the classroom allows everyone to see how they respond to disabled people, especially when that representation is in the form of case studies and client role-play. Then, everyone, including supervisors, can constructively receive feedback from a trusted figure and can change or improve their reactions and responses if necessary. Furthermore, counselor educators and counselors-in-training can keep reflective journals, seek supervision or peer discussions, and review case notes with an anti-ableist lens, which can help identify areas for growth. Additionally, counselor educators should actively solicit feedback from the disability community, welcoming their perspectives without defensiveness. When possible, attend training led by disabled professionals and the disabled community to reinforce a commitment to continuous learning and accountability.
Implications for Counselor Educators
Counselor educators are responsible for training counselors to work with all types of clients, including disabled clients. Counselors will encounter disabled clients, no matter the setting that they are working in. Disability can impact anyone and does not discriminate across gender, race, socioeconomic status, sexual orientation, or geographic location. Disability is the one minority group that anyone can become a part of at any time in their life. Most people will age into disability as they get older (Shapiro, 1994). Counselor educators need to be sure that counselors are confronting and dismantling their own ableism and ableist beliefs and that they understand that they may need to assist clients in processing their own experiences with ableism in society and interactions with others. One self-assessment for self-reflection and insight is the Systematic Ableism Scale (SAS; Friedman, 2023). The SAS has four underlying themes: individualism, recognition of continuing discrimination, empathy for disabled people, and excessive demands. The SAS is a tool that can be used to help understand how contradicting disability ideologies manifest in modern society to determine how best to counteract them. By using this assessment as a self-evaluation tool, both students and counselor educators can identify where their beliefs may be problematic or ableist and then set goals to address and improve in those areas.
We recommend that counselors intentionally occupy spaces where discussions on disability advocacy are occurring. Universities are often regarded as a primary source of knowledge production, but a common misconception is that the people themselves produce the knowledge. The reality is that not all disability content is produced by disabled individuals or organizations. Thus, we encourage counselor educators to expand access to knowledge about disability by seeking spaces outside the institution that share insider perspectives on the disability experience and organizations dedicated to empowering disabled communities. This may involve engaging with informal educational organizations such as Sins Invalid, AXIS Dance Company, and Krip Hop Nation or getting involved with formal professional organizations such as APA Division 22, the American Rehabilitation Counseling Association, or the National Rehabilitation Counseling Association. Some strategies that can be used to advocate for and in support of disabled clients include client-centered advocacy, understanding disability as a cultural identity, and building knowledge of the disability rights movement, ableism, and intersectionality, as well as integrating disability-inclusive language, avoiding ableist assumptions, and incorporating clients’ lived experiences into treatment (Chapin et al., 2018; Smart, 2015; Smith et al., 2011).
The foundation for a competent and qualified counselor begins with their training. This training can be formal education or ongoing professional development. For those responsible for educating counselors-in-training, laying the foundation for anti-ableism practices begins in the classroom. A universal design for learning (UDL) framework, developed by the Center for Applied Special Technology (CAST, 2018), aims to create accessible material and inclusive environments that are usable for all people by intentionally incorporating multiple representations of content to enhance student expression of learning and increase a variety of opportunities for engagement with the learning environment (Black et al., 2015; Dolmage, 2017; Fornauf & Erickson, 2020). UDL principles support anti-ableist practice by encouraging an ongoing partnership between students and instructors that facilitates consistent and practical feedback to promote student belongingness (Hennessey & Koch, 2007; Oswald et al., 2018). Promoting belonging and acceptance in counselor education programs requires intentional strategies that foster inclusivity, respect for diversity, and a strong sense of community. Effective techniques include: 1) Use inclusive curriculum design. Integrate diverse perspectives throughout the curriculum, with special attention paid to marginalized voices, such as disabled voices. 2) Use culturally responsive pedagogy. This includes employing a range of instructional methods to cater to diverse learning styles. Use trauma-informed practices by creating a learning environment that is sensitive to trauma, both past and present. 3) Implement community-building activities such as structuring programs around cohorts and encouraging the formation of affinity groups and peer support groups. 4) Encourage active dialogue and reflection around tough conversations such as diversity, ableism, inequality, and marginalization. This can be done both in person and online via discussion boards. Faculty can also encourage students to explore their thoughts, reflections, and experiences around issues of identity, belonging, and ableism in a reflective journal. 5) Collect feedback to guide continuous improvement. Faculty can assess students’ experiences with inclusion and ableism through climate surveys.
Additionally, the adoption of multiple methods for delivering information in alternate formats and continuous assessment of student progress reduces barriers to student engagement and expression in the learning environment, which in turn systematically challenges normative ableist practice that values a one-size-fits-all perspective that often neglects disabled thought and existence in pedagogical practices (Oswald et al., 2018). UDL strategies to disrupt ableist thought and practices may include using closed captioning on visual multimedia content (e.g., videos, PowerPoint presentations), incorporating movement breaks, creating interactive activities (e.g., role-play activities, gamification, debates on critical topics), and receiving feedback on instruction.
Hill and Delgado (2023) discussed the importance of including disability coursework and content across multiple domains to effectively address ableism in counselor education programs. Building upon their work, we suggest that the following key types of coursework and content be included. At a minimum, disability content should be integrated into the core CACREP curriculum areas: professional counseling orientation and ethical practice, social and cultural foundations, lifespan development, career development, counseling practice, group counseling, assessment and diagnosis, and research and program evaluation (CACREP, 2023).
Foundational Disability Studies
Students should explore and understand how ableism developed and its systemic nature, especially in the current political climate (Campbell, 2009; Dolmage, 2017). Additionally, students can learn about models of disability: medical, sociopolitical, functional, religious, moral, and biopsychosocial (Engel, 1977; Shakespeare, 2006; Smart, 2015). Students must also understand the concept of intersectionality, which examines how disability interacts with race, gender, sexuality, and socioeconomic status (Erevelles & Minear, 2010; Garland-Thompson, 2005).
Ethics and Multicultural Competence
Students should understand the intersection of disability and ethics by being able to apply the ACA Code of Ethics to disability issues (Chapin et al., 2018; Feather & Carlson, 2019). In either an ethics class or a multicultural class, students must learn about crucial disability-related legislation, such as the Rehabilitation Act of 1973, the Americans with Disabilities Act, the Individuals with Disabilities Education Act, and the Workforce Innovation and Opportunity Act. In the multicultural class, students need to understand disability cultural competence and receive training on disability as a cultural identity and recognizing ableism as a form of oppression (Feldner et al., 2022; Smith et al., 2011). Additionally, in the multicultural class, students should be taught about biases and microaggressions, as well as how to identify and address ableist language and behavior.
Counseling Skills and Practice
In a counseling skills class, students must learn accessible counseling techniques, such as modifying approaches for different abilities (e.g., sensory, cognitive, mobility). Students should also be presented with case studies involving disabled clients, with an emphasis on strengths-based and person-centered approaches. Additionally, students ought to receive supervision and advocacy training on how to support and advocate for clients with disabilities in clinical settings. Counselor educators can use the strategies listed here in the classroom and in practice.
Directions for Future Research
Two of the three authors of this article are disabled and bring lived experience to their teaching, writing, research, and engagement with the nondisabled world. This real-world experience informs the strategies presented and has been applied in both classroom and professional settings. However, these approaches have not yet been empirically tested through formal research. Future research could focus on empirically validating these strategies through qualitative or quantitative studies, particularly in evaluating confidence when working with disabled clients before and after implementing these strategies. Strategies include incorporating disability knowledge into the counselor education curriculum coursework (Hill & Delgado, 2023), using critical pedagogy and disability justice frameworks when teaching (Dolmage, 2017; Erevelles & Minear, 2010), providing experiential learning and opportunities for contact with disabled individuals (Smith et al., 2011), giving disability-related education and training for faculty and supervisors (Feldner et al., 2022), and encouraging the development of allyship and advocacy skills (Feldner et al., 2022; Goodman et al., 2004). Additional studies are also needed to examine ableism and confidence in teaching anti-ableist concepts and disability-related competencies by counselor educators. Finally, scales or measures to assess ableism, specifically in counselor education, could be created and validated.
Conclusion
These strategies do not aim to be an all-encompassing, definitive, or exhaustive checklist, as there are many ways to dismantle ableism. These strategies are a starting point, a reminder, a point of reflection, or an opportunity to affirm current strategies. Significantly, these strategies extend beyond counseling and are relevant across various educational and professional settings, from K–12 classrooms to higher education, social work, health care, and beyond. Wherever you land, we invite you to continue learning, growing, and committing to change with us. Alice Wong (2020) proclaimed, “There is so much that able-bodied people could learn from the wisdom that often comes with disability. However, space needs to be made. Hands need to reach out. People need to be lifted up” (p. 17). Together, we can extend our hands, challenge systemic barriers, and work to dismantle ableism in counseling settings and across all aspects of society.
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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Julie C. Hill, PhD, NCC, BC-TMH, LPC, CRC, is an assistant professor at the University of Arkansas. Toni Saia, PhD, CRC, is an associate professor at San Diego State University. Marcus Weathers, Jr., PhD, CRC, LPC-IT, is an assistant professor at Mississippi State University. Correspondence may be addressed to Julie C. Hill, 751 W. Maple St., Fayetteville, AR 72701, jch029@uark.edu.
Aug 26, 2025 | Volume 15 - Issue 3
Mykka L. Gabriel, Laura G. Dunson Caputo, Jenny L. Cureton
Despite rising suicide rates and disparities in minoritized communities as well as calls from experts and community leaders to address cultural factors, most suicide risk assessment (SRA) approaches remain acultural. Counselors who use acultural SRA can cause harm by neglecting to address crucial factors that may heighten or protect clients from suicide risk. This article provides guidance for proactive and responsive broaching in SRA using the four dimensions of the Multidimensional Model of Broaching Behavior (Day-Vines et al., 2020). The model provides an overview of key concepts, explicit recommendations for counselors in diverse settings, and an illustrative case example. Concerns, limitations, and implications for counselors, supervisors, educators, and researchers are addressed.
Keywords: suicide, risk assessment, broaching, cultural factors, acultural
Recent suicide data demonstrate ongoing demographic disparities. Centers for Disease Control and Prevention (CDC; 2025) data showed an increase in suicide between 2018 and 2023 for some non-White racial groups, including a 25.2% increase among Black Americans and 10% increase among Hispanic persons. With a suicide rate of 23.8%, American Indian or Alaska Native persons continue to have the highest rate. Suicide ideation is more than twice as prevalent for adults with disabilities than those without disabilities (Czeisler et al., 2021). Kidd et al. (2023) found that significantly more transgender adults had attempted suicide than cisgender adults: 42% versus 10.6%. In a meta-analysis, Cogo et al. (2022) found that immigrants and refugees are at high risk for suicidal ideation, with rates as high as 70% in some groups. Risks also increase for immigrants and refugees if they experience trauma, socioeconomic disadvantage, or a lack of accessible care.
Recent surveys have highlighted the elevated suicide risk among LGBTQ+ youth with intersecting marginalized identities. Compared to White LGBTQ+ youth, non-White groups reported higher rates of suicidal ideation and attempts. For example, 43% of White, 46% of Latinx, and 55% of Native/Indigenous LGBTQ+ youth attempted suicide in 2022 (The Trevor Project, 2023). Findings from the 2024 survey continued to show higher rates of suicidal ideation among LGBTQ+ youth of color (The Trevor Project, 2024). Sallee et al. (2022) found similar results in their study on interpersonal predictors of suicide among “not straight” adolescents. The authors also highlighted the need for further research on the “unique stressors” of non-White “not straight” students. Collectively, these studies emphasize the necessity of integrating connections between suicide risk and minoritized identity.
Critical suicidology is an emerging qualitative approach increasingly recognized in the mental health field wherein suicidal experiences are contextualized through a cultural and social lens (Marsh, 2020; White, 2017). Community and government leaders have urged professionals to address cultural factors of suicide (Miller & Castle Work, 2024; Rhodes, 2023; U.S. Department of Health and Human Services [DHHS], 2024), which are both individual as well as socioecological (Compton et al., 2005; Day-Vines, 2007; Molock et al., 2023). For instance, systematic oppression is associated with increased suicide risk (Alvarez et al., 2022; Fulginiti et al., 2021). Other contextual factors, such as cultural sanctions and family or social conflict, are better predictors of suicide attempts than acultural factors (Chu et al., 2019; Compton et al., 2005). Acultural understandings of suicide do not include cultural considerations; instead, they only cover “classic risk and protective factors” (Chu et al., 2019, p. 56) such as depression (Chu et al., 2019; Khan, 2005), substance abuse (Lawson-Te Aho & Liu, 2010), and reasons for living (Chu et al., 2019), which are typically conceptualized without acknowledging systemic contributors (Hazan & Romberg, 2022; Lawson-Te Aho & Liu, 2010).
Counseling research has shown that mental health symptoms of Black, Indigenous, and people of color can present differently than those of White clients (Litam, 2020; Wright et al., 2023). However, most suicide risk assessment (SRA) approaches are acultural, which means that they lack consideration of sociocultural factors in suicide risk (Chu et al., 2019; Mendoza-Rivera et al., 2022). Neglecting to address culture in SRA can cause serious misunderstandings of the client’s experience and underestimate their risk of suicide (Rogers & Russell, 2014; Van Zyl et al., 2022). Counselors must consider suicide risk in the context of culture in order to meet clients’ needs as well as to maintain ethical and practice standards (American Association of Suicidology [AAS], 2023; American Counseling Association [ACA], 2014; Ratts et al., 2016). Yet, scant counseling literature (Chu et al., 2013; Molock et al., 2023) provides concrete guidance on how to address culture while assessing suicide risk.
Integrating the Multidimensional Model of Broaching Behavior (Day-Vines et al., 2020) into SRA procedures is a plausible solution for these challenges. Broaching explores racial, ethnic, and cultural (REC) contexts throughout the counseling process (Day-Vines et al., 2007). Broaching applications have been well-documented in the counseling literature (Bayne & Branco, 2018; Day-Vines et al., 2007, 2020; Jones et al., 2019; Jones & Welfare, 2017; King, 2021). In a recent Counseling Today article, counselors noted cultural norms that may exacerbate suicide risk and the use of broaching to build trust (Rhodes, 2023). Our article describes an application of the broaching model (Day-Vines et al., 2020) used in tandem with evidence-based SRA tools when assessing suicide risk with minoritized clients. We briefly review the intersection of culture and suicide, review broaching, compare acultural with culturally responsive SRA, and present the potential of broaching to address the barriers mentioned above. The proposed broaching application contains suggestions for when, what, and how to broach culture for SRA, along with brief illustrative examples. We include implications for counseling, supervising, and teaching, then conclude with critical considerations for counselors and directions to research broaching for culturally responsive counseling related to suicide.
Culture and Suicide
Recommended practice for SRA includes the combination of a formal instrument, or lethality measurement scale, and a clinical interview about the client’s protective factors, ideation, intent, plans, access to lethal means, behavior, and warning signs (AAS, 2023; Jackson-Cherry et al., 2017). Clinical judgment should consider “developmental, cultural, and gender-related issues related to suicidality” (AAS, p. 2). Cultural factors, such as oppression, stigma, misconceptions, and community disconnection, can influence suicide risk. A primary factor driving suicide risk is cultural oppression, including historical trauma, structural racism, and other discrimination (Fulginiti et al., 2021). Suicide risk is higher for individuals with multiple oppressed identities (Vargas et al., 2020), such as Latinx LGBTQ youth (Abreu et al., 2023). People from marginalized communities, such as sexual, gender, and racial minorities (Ayhan et al., 2019; Sim et al., 2021) and people with disabilities (Krahn et al., 2015) face harmful oppression from the health care system itself because of bias and preconceived judgments on presenting behaviors (Johnson, 2024).
Members of these communities also experience stigma and misconceptions. Several instruments measure suicide stigma or negative judgments toward people experiencing suicidal thoughts (Nicholas et al., 2023). Internalizing suicide stigma or stigmatizing messages about one’s minoritized identities increases suicide risk (Carpiniello & Pinna, 2017). Some suicide misconceptions are related to culture. For example, James et al. (2023) found misunderstandings among Black Americans that suicidal thoughts are temporary or not real and that only people from other races or those too weak to deal with life stressors have such thoughts.
These cultural factors can influence whether and how individuals seek support for suicide. Members of marginalized groups report avoiding seeking professional help because of health care oppression (Dautovich et al., 2021). They may not disclose suicidal thoughts to professionals, family, or friends based on messages in their cultural community that doing so would make loved ones disappointed in them, bring shame to their family, and/or prompt their isolation from the community (Knapp & Logan, 2023; Molock et al., 2023).
Suicide protective factors (SPFs) are internal and external factors that create protective barriers that reduce death by suicide (Crosby et al., 2011). Other cultural factors may protect against suicide. Most ethnoracial groups experience social support, community connectedness, and ethnic identity as SPFs (Odafe et al., 2016; Wang et al., 2020). Support from family and friends also acts as an SPF for LGBTQ+ individuals, including queer youth of color (Lardier et al., 2020) and transgender/gender-diverse adults (Rabasco & Andover, 2021). It is important to note that religious, moral, or cultural objections to suicide may be an SPF for some but a risk factor for others in their cultural group and can change from protecting to exacerbating an individual’s suicide risk because of isolation or distress from stigmatizing messages (Odafe et al., 2016; Sharma & Pumariega, 2018).
Competent counseling for suicide involves assessing for suicide risk factors and SPFs and then using that information to inform interventions and continuity of care (AAS, 2023). Standard suicide assessment practices are largely acultural, omitting essential factors like race, ethnicity, and culture in a client’s suicide risk (Chu et al., 2013; Day-Vines, 2007; Molock et al., 2023; Van Zyl et al., 2022). Common SRA tools include the Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008), the Collaborative Assessment and Management of Suicidality (Jobes & Drozd, 2004), and the Ask Suicide-Screening Questions (Horowitz et al., 2012). For example, nearly two decades of C-SSRS validation provides evidence across 10 psychometric properties (The Columbia Lighthouse Project, n.d.). This research has examined samples diverse in setting, diagnoses, age, and cultural demographics, and it has been translated into over 150 languages. The C-SSRS contains questions related to suicide ideation, intensity, and behavior to determine the level of risk (Posner et al., 2008). It has shown high specificity in multiple studies (Kumar et al., 2025) and is one of the few suicide scales that demonstrates sensitivity to change in suicide risk across time (Riblet et al., 2023). However, researchers have noted a persistent lack of meta-analyses investigating the C-SSRS and similar acultural measures with culturally diverse samples (Nam et al., 2024; Pollak et al., 2024).
A few recent SRA tools explicitly address culture, including the Cultural Assessment of Risk for Suicide (CARS; Chu et al., 2013); its screener version, CAR-S (Chu et al., 2018); and SHORES (Cureton & Fink, 2019). CARS is a formal instrument tested with samples including racial, ethnic, and sexual minority adults (Chu et al., 2013, 2019). These validation studies showed acceptable internal consistency for its subscales and high internal consistency overall compared to acultural SRA measures. A recent investigation of CARS with Black American adolescents (Francois et al., 2025) revealed acceptable internal consistency overall but divergent factor structure, indicating that the modified version of CARS-S may not adequately represent minority stress, family conflict, or cultural objections in Black youth suicide risk. SHORES (Cureton & Fink, 2019) is an SPF mnemonic to support recall during SRA, safety planning, and other suicide prevention, intervention, and postvention. To date, no research on its use has been published. Counselors can also utilize the Cultural Formulation Interview (CFI; American Psychiatric Association, 2022) to assess the cultural context of diagnostic symptoms. Whether an SRA tool is acultural or culture-focused, empirically supported or still emerging, two recommendations are consistent in the literature: 1) use it only as an initial or adjunct tool toward comprehensive suicide assessment (e.g., Cureton & Fink, 2019; Kumar et al., 2025) and 2) make adaptations to better address culture (e.g., Chu et al., 2019; Francois et al., 2025; Pollak et al., 2024).
Suicide Risk Assessment and Clinical Interview
As previously stated, recommended SRA practice consists of an evidence-based tool and a clinical interview (AAS, 2023; Jackson-Cherry et al., 2017). Counselors can integrate broaching into the clinical interview to explore cultural factors that shape the client’s level of risk and their subjective experience. We used the C-SSRS (Posner et al., 2008) for illustration and built on previous guidance for broaching practices in counseling (Day-Vines et al., 2020; Erby & White, 2022; Jones & Welfare, 2017) to recommend ways counselors can incorporate cultural considerations effectively into the SRA interview. Although broaching may benefit culturally responsive suicide intervention and ongoing management, we focused on its use in counselor–client collaborative risk assessment as a first step for improved practice.
Broaching
Day-Vines et al. (2007) coined the term broaching to define the counselor’s “ability to consider the relationship of racial and cultural factors to the client’s presenting problem, especially because these issues might otherwise remain unexamined during the counseling process” (p. 401). Broaching facilitates dialogues regarding power and privilege (Erby & White, 2022), strengthens the therapeutic relationship (Knox et al., 2003), and deepens alignment with the Multicultural and Social Justice Counseling Competencies (Day-Vines et al., 2007; Ratts et al., 2016). Broaching has four dimensions of counselor acknowledgment (Day-Vines et al., 2020): (a) intracounseling: REC similarities, differences, and interpersonal processes in the counselor–client relationship; (b) intraindividual: confluence of the client’s identities; (c) intra-REC: within-group concerns between the client and one or more of their cultural communities; and (d) inter-REC: the client’s experiences of oppression. As shown in Table 1 and described below, counselors can integrate each dimension to elicit discussion about culture alongside an evidence-based SRA tool.
Table 1
Multidimensional Model of Broaching Behavior in SRA
| Dimension |
Purpose |
Focus in SRA |
| Intracounseling |
Acknowledges similarities, differences, and interpersonal processes that may impact the
client–counselor relationship |
Invites the client to take the lead role as the expert of their experience and formulate a genuine trust between the client and counselor |
| Intraindividual |
Acknowledges intersecting
identities that shape the client’s experience and view of their presenting concern |
Invites the client and counselor to explore connection(s) between intersecting REC-specific experiences and suicidal ideation |
| Intra-REC |
Identifies within-group concerns between the client and one or
more of their cultural communities |
Creates an opportunity to explore the context of the client’s belongingness, possible isolation, coping, and contribution to follow-up care |
| Inter-REC |
Acknowledges the client’s experiences specific to racism, oppression, and social justice |
Creates an opportunity for the client and counselor to specifically address barriers and disparities that directly contribute to the client’s suicidal ideation |
Note. Table 1 includes the purpose of each MMBB dimension (Day-Vines et al., 2020) and its corresponding focus applied in SRA. Specific examples appear throughout the case study. REC = racial, ethnic, and cultural.
Application of the Multidimensional Model of Broaching Behavior in Suicide Risk Assessments
Broaching race, ethnicity, and culture is crucial in culturally responsive SRA. We propose this approach as an additive component with evidence-based tools (e.g., the C-SSRS). Broaching during the interview provides essential context for results to inform a comprehensive assessment of the client’s suicide risk. Using a case example, we explain how counselors can practically incorporate each dimension of broaching within the SRA clinical interview process.
Case Study
Elliana (she/her) presents to the university counseling center for a walk-in appointment. She is a 19-year-old first-generation college student from another state and identifies as a Black cisgender lesbian. She remembered that her professor mentioned the counseling center at the start of the semester and noticed its promotion as LGBTQ+ inclusive with culturally responsive counselors. Elliana finds it difficult to concentrate, which has resulted in lower grades. Her counselor, a Black heterosexual woman, notices that Elliana has indicated headaches, lack of sleep, feelings of hopelessness, sadness, and suicidal ideation on her intake paperwork. Elliana has not verbally disclosed her suicidal ideation to her counselor. Elliana tells her counselor she has a strong relationship with her family and a strong LGBTQ+-affirming community in her hometown. Elliana is the eldest of three from an intact family. Elliana reports feeling disconnected and isolated at school. Despite participating in various student organizations, Elliana feels like an “outsider” with little sense of belonging and conflicts with her roommate. Elliana shares that she has not disclosed her sexual orientation to her roommate because her roommate made negative comments about the LGBTQ+ community and listens to podcasts with anti-LGBTQ+ rhetoric. The counselor’s primary goal in her first interaction with Elliana is to build a therapeutic relationship and assess for safety. She administers the C-SSRS, which indicates a low level of risk (e.g., Elliana denies having any intent or plan). Therefore, the counselor can assist Elliana with a safety plan and follow-up care. To ensure a more comprehensive understanding of her risk, the counselor incorporates broaching questions to explore how Elliana’s cultural background and lived experiences influence her thoughts and coping.
Opportunities for Broaching
An element of integrating broaching in SRA is determining when to do so. SRA (AAS, 2023) and broaching (Day-Vines et al., 2020) should involve an ongoing and collaborative process. Two forms of broaching are proactive and responsive (Day-Vines et al., 2013; King, 2021). We describe each form as an opportunity to broach SRA with Elliana.
Proactive Broaching
Proactive broaching involves a counselor-led orientation to discussing cultural experiences (King, 2021). Proactive broaching initiates opportunities for clients to discuss cultural concerns (Day-Vines et al., 2020), encourages client openness (Drinane et al., 2018), and ensures more accurate information during diagnosis and assessment (King & Borders, 2019). Proactive broaching ranges from a question on a structured intake to the counselor first introducing cultural considerations into the risk assessment. For Elliana, her counselor may say, “As I’m getting to know you, can you tell me a bit about your culture?” Counselors can strengthen their proactive broaching by providing a rationale for the topic change; addressing verbal and nonverbal reactions to broaching; and utilizing skills of active listening, paraphrasing, and reflections (King & Jones, 2019).
Responsive Broaching
Responsive broaching involves a counselor’s response to a client’s disclosure (Day-Vines et al., 2020; King, 2021). This helps counselors avoid broaching at the wrong time and can particularly benefit counselors who use an organic, conversational counseling style rather than a structured style (Jones & Welfare, 2017). Responsive broaching manifests uniquely based on the situation. Counselors can respond to the client’s spoken cultural content using clinical skills. For example, in response to Elliana telling her counselor that she has a strong relationship with her family and a strong LGBTQ+-affirming community in her hometown, her counselor may paraphrase Elliana’s cultural protective factor by stating, “It sounds like you feel closely connected to your family and the LGBTQ+ community back at home. How do your connections affect your thoughts of suicide?” Responsive broaching could also invite the counselor to be more specific by asking, “How does being a part of a Black family and the LGBTQ+ community influence your thoughts of suicide?” This may invite Elliana to expand on these connections as protective factors contributing to her sense of belonging (Cureton & Fink, 2019).
Because Elliana shares common adjustment experiences with out-of-state first-year students (e.g., anxiety, time management), her counselor may utilize open questions to clarify cultural idioms of distress (APA, 2022). Counselors can also respond to a client’s unspoken cultural content. For example, clients may discuss cultural experiences, such as marginalization or belonging, without explicitly referencing specific cultural identities or terms. Counselors can broach these moments responsively by asking for clarity or gently positing the possibility of culture. For example, Elliana’s counselor may notice her isolation as a potential suicide risk and state, “I heard you say you are feeling like an outsider. Does being a young first-generation college student or having other cultural experiences play a role in your thoughts to kill yourself?” Counselors can strengthen responsive broaching by attending to client responses and utilizing immediacy to process the experience of discussing culture.
Content of Broaching
Another element of integrating broaching in SRA is determining what to broach. Both broaching (Day-Vines et al., 2020) and suicide assessments (AAS, 2023) encompass clients’ holistic experiences, suggesting that broaching can include any part of the client’s lived experience. King (2021) indicated that broaching typically serves one of two purposes: broaching cultural similarities and differences within the counseling relationship or broaching cultural content within the client’s experience. Similarly, Day-Vines et al. (2020) illustrated four dimensions of broaching: intracounseling, intraindividual, intra-REC, and inter-REC. We propose that the Multidimensional Model of Broaching Behavior can be used as a guide for counselors to utilize during the interview process of the suicide risk assessment. This section includes an interactive review of each dimension of broaching regarding an SRA with Elliana.
Intracounseling
Broaching the intracounseling dimension includes broaching similarities, differences, and interpersonal processes between client and counselor (Day-Vines et al., 2020), which communicates to the client that talking about race, ethnicity, and culture is permissible and explores how to navigate these topics within the counseling relationship (Day-Vines et al., 2020). Broaching cultural experiences within the counseling relationship strengthens the relationship (King, 2021). Counselors can broach intracounseling factors proactively or responsively. In the case of Elliana, her counselor may proactively broach by saying:
I often ask clients about their cultural identities during a suicide assessment because I want to understand how culture may play a role in their experience of suicide and mental health. We are both Black women, but I try not to assume our experiences are the same. For example, I am older than you, and we may have different generational experiences. We may also have other identities and cultural experiences that are different. I encourage you to share your experiences with me as we go through this assessment.
Here, the counselor comments on observable shared identities and invites Elliana to share her cultural experiences. The counselor also tells Elliana that she is the expert in her experience.
Counselors can also broach intracounseling factors responsively. Broaching for the relationship responsively involves identifying cultural concerns in the client’s disclosure and inviting discussion contextualized within the counseling relationship (Day-Vines et al., 2020). For example, a counselor may say, “You mentioned that you decided to come to the counseling center because your professor mentioned we are culturally responsive and LGBTQ+ affirming. I am here to support you, and together, we will make a plan of action.” With each approach, her counselor is direct and invites therapeutic support by intentionally keeping the client’s identities at the center of their relationship.
Intraindividual Factors
Counselors can assess intraindividual factors (Day-Vines et al., 2020) related to suicide, such as how cultural experiences may influence suicidality. The counselor explores Elliana’s experiences related to her intersecting identities and possible connections to her suicidal ideation. For example, the counselor may initially assess intraindividual factors by introducing the exploration: “Thank you for sharing your identities with me. You told me you do not feel like you belong, despite being involved in various activities. Could you tell me more about not belonging?” The counselor would use clinical skills to explore Elliana’s sense of belonging, reflecting on her experiences and possible distress connected to her intersecting identities.
Intra-REC Dimension
Counselors can assess the intra-REC dimension, which includes within-group concerns between the client and one or more of their cultural communities (Day-Vines et al., 2020) related to suicide. The counselor could continue to explore the differences between Elliana’s strong connections with her family and the LGBTQ+ community in her hometown and her lack of school belonging as a first-generation college student. For example, a counselor may ask Elliana, “I’m hearing you’re involved in various campus organizations, yet you feel like an outsider. From your perspective, what, if any, cultural factors contribute to this feeling?” This conversation could introduce a conversation about existing coping skills and her interpretation of her experiences. The counselor could use this information to assist with identifying Elliana’s needs, along with a focused follow-up care plan for appropriate mental health services.
Inter-REC Dimension
Counselors can assess the inter-REC dimension, which is the client’s experiences of oppression (Day-Vines et al., 2020) related to suicide. Elliana talked about her roommate making negative comments and listening to podcasts with anti-LGBTQ rhetoric. The counselor could assess the level of impact of this concern relating to her suicidality by asking “When you hear your roommate make negative comments and listen to podcasts with anti-LGBTQ rhetoric, what thoughts come to your mind?” Questions like this can help Elliana connect her own experiences and allow her to clarify if and how her roommate contributes to her suicidal ideation.
Discussion
This case study provides several factors to consider alongside an evidence-based SRA. Counselors must follow the guidelines of an SRA to ensure client safety and protective factors and make informed decisions for continuity of care. The intentional use of the Multidimensional Model of Broaching Behavior can serve as a guide to assist counselors in applying an integrative approach to the SRA interview process. Establishing trust between client and counselor can encourage insight into the client’s unique needs. The Multidimensional Model of Broaching Behavior provides the framework for intentional relationship building and conceptualizing the client—in this case, Elliana—through her overlapping identities (young adult, first-generation college student, Black, cisgender, and lesbian).
Broaching race, ethnicity, and culture applies to all clients and is not exclusive to cross-cultural experiences (Bayne & Branco, 2018). In alignment with current research (Bayne & Branco, 2018; Erby & White, 2022), broaching can be a valuable tool for assessing risk while recognizing and validating the client’s unique experiences, regardless of whether they share identities with the counselor. This idea aligns with other scholars who suggest that “all counseling is multicultural counseling” (Ivey & Ivey, 2001). Culturally competent counselors are encouraged to self-explore their broaching attitude (i.e., avoidant; Day-Vines et al., 2007, 2020) for an insightful self-assessment of the multiple dynamics within the crisis therapeutic relationship.
Broaching is a promising approach to exploring culture during SRA. However, there are some considerations. First, the nature of acute crisis often requires that responders abbreviate their assessment and hasten action to best prevent risk (Collins & Collins, 2005). In these circumstances, counselors may need to prioritize acultural SRA prompts and/or vary broaching statements based on the goal at hand (King, 2021). For instance, counselors might broach content to conceptualize risk for an immediate plan, or they might broach the relationship to promptly reduce the power differential. Indirect and/or closed-ended broaching (e.g., “Even though we are different, I want to understand what is happening for you right now so we can be together on this.”) may be sufficient in time-limited crisis response.
Second, counselors will ineffectively apply broaching if they expect universal client reactions. Day-Vines et al. (2007) suggested that client reactions to broaching vary based on internal and external factors. For example, a client may prefer to focus on a specific pressing concern instead of discussing culture. Counselors should follow the client’s lead in how culture informs the remaining SRA. If Elliana had declined to discuss her intra-REC experiences when her counselor asked about cultural factors when she feels like an outsider in various campus organizations, the counselor should refrain from asking further questions or details to respect her decision.
Implications for Counselors
There are implications for counselors when using broaching during SRA. Rather than replacing existing practice, a counselor can incorporate broaching into their typical SRA procedures. A broaching conversation with an instrument that explicitly addresses culture, such as CARS or CARS-S (Chu et al., 2013, 2018), may provide a smooth orientation to the survey and/or support nuanced exploration of its results. Counselors can prepare to use broaching in SRA by understanding which cultural factors typically increase suicide risk and which operate as protective factors. Attuning to these factors during SRA may help counselors explore social determinants of mental health (Lenz & Lemberger-Truelove, 2023; Lenz & Litam, 2023). The scope of this article was necessarily limited to SRA because of its conceptual and logistical complexity in counselor practice; however, broaching factors and determinants can inform case conceptualization, safety planning, ongoing counseling intervention, and case management.
Implications for Educators and Supervisors
Implications of broaching in SRA also exist for educators and supervisors. Their professional roles include preparing trainees to address crises and provide culturally responsive care (ACA, 2014; Council for the Accreditation of Counseling and Related Educational Programs [CACREP], 2023). Preparing trainees and licensed counselors to broach in SRA aligns with current counseling literature that advocates for improvements to suicide training (Binkley & Elliot, 2021) and a social justice framework for supervision (Dollarhide et al., 2021). Educators and supervisors would benefit from ongoing professional development, reflexive practices, and consultation to prepare them to address broaching in SRA.
Educators can introduce broaching strategies during suicide counseling instruction. This integration could help programs address CACREP (2023) standards on suicide (G.16) and multicultural counseling (Section B). Students who received suicide counseling instruction before practicum reported lower anxiety (Binkley & Leibert, 2015) and higher levels of preparedness, knowledge, and comfort in suicide response (Shannonhouse et al., 2018). Introducing broaching strategies during suicide counseling instruction has the potential to produce similar results.
Supervisors can integrate broaching SRA into supervision practice. Supervisors can broach culture within the supervisory relationship (King & Jones, 2019) to strengthen the supervisor’s understanding of the supervisee’s culture, help the supervisee comprehend their own positionality in counseling and supervision, and increase the supervisee’s understanding of broaching itself. Supervisors use discussion and case conceptualization to support supervisees’ preparedness for SRA, broaching, and their synthesis. Modeling or roleplaying broaching (Erby & White, 2022; Jones et al., 2019) in SRA may help supervisees practice skills.
Future Directions
Future scholarship can explore broaching race, ethnicity, and culture in SRA even when the client is not affiliated with a minoritized status. For instance, a White, Christian, heterosexual, cisgender male may hold multiple privileged identities, yet White males continue to show high suicide death rates (CDC, 2025). Counselors may consider using a similar approach to proactive and responsive broaching to inquire about religious and family values, social ideals, and beliefs about suicide, which shape both risk and protective factors.
Research on broaching in SRA is needed to determine the impact on client conceptualization, clinical decision-making, and postvention. Qualitative research with counselors and minoritized clients could provide insight into the experiences of broaching in SRA, informing clinical perspectives on topics such as relativity, therapeutic rapport, and training needs. Quantitative research might reveal the differential effectiveness of SRA with and without broaching. A future investigation of the Broaching Attitudes and Behavior Survey (Day-Vines et al., 2013, 2024) may determine the effectiveness of broaching in SRA. Educational research may assess the impact of incorporating broaching into SRA instruction (e.g., on confidence and skill development) and supervision in practicum and internship. Another direction is to advance the applications for broaching for intervention and ongoing management of suicide in counseling.
Conclusion
People from minoritized groups experience increased suicide risk (CDC, 2025; Czeisler et al., 2021; Kidd et al., 2023; The Trevor Project, 2023) and specific suicide risk and protective factors, such as systemic oppression (Alvarez et al., 2022; Fulginiti et al., 2021), cultural sanctions against suicide, and the impact of family/social relationships (Chu et al., 2019; Compton et al., 2005). Despite ethical and practice standards (AAS, 2023; ACA, 2014; Ratts et al., 2016) and calls from professional and community leaders (DHHS, 2024; Miller & Castle Work, 2024), most SRA practice neglects these factors (Mendoza-Rivera et al., 2022), which can increase harm (Rogers & Russell, 2014; Van Zyl et al., 2022). Counselors can improve their SRA practice by utilizing the Multidimensional Model of Broaching Behavior (Day-Vines et al., 2020) to explore REC contexts (Day-Vines et al., 2007) during initial and repeat assessments to inform intervention. Supervisors and educators can inform and guide counselors in broaching in SRA to ensure ethical and effective practice. Existing research demonstrating the positive impacts of broaching can expand to examine its use for assessing suicide risk for clients across identities.
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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Mykka L. Gabriel, LPCC-S, is a doctoral candidate at Kent State University. Laura G. Dunson Caputo, PhD, LPCC-S, is an assistant professor of practice at John Carroll University. Jenny L. Cureton, PhD, LPCC (OH), LPC (CO, TX), is an associate professor at Kent State University. Correspondence may be addressed to Mykka L. Gabriel, Kent State University, White Hall 310, PO Box 5190, Kent, OH
44240-0001, mgabri12@kent.edu.
Jul 25, 2025 | Volume 15 - Issue 2
Sara E. Ellison, Jill M. Meyer, Julia Whisenhunt, Jessica Meléndez Tyler
Nonsuicidal self-injury (NSSI) has historically been associated with deficits in impulse control; however, evidence suggests that individuals high in self-control also self-injure. This constructivist grounded theory study aimed to explore the nature of undercontrolled and overcontrolled self-injury to fill gaps in the literature and to improve clinical understanding and treatment. The resulting Theory of Overcontrolled and Undercontrolled Self-Injury provides a preliminary understanding of the mechanisms that guide overcontrolled and undercontrolled NSSI, the processes that can facilitate individuals switching profiles, and the processes that lead to cessation of self-injurious behavior, thereby contributing to the development of more comprehensive theories of self-harm. Additionally, clinical implications for developing assessments and interventions aimed at preventing and treating NSSI are discussed.
Keywords: nonsuicidal self-injury, self-control, undercontrolled, overcontrolled, self-harm
Nonsuicidal self-injury (NSSI) is the act of intentional, self-inflicted damage of body tissue without the intent to end one’s life and for purposes not socially or culturally sanctioned (Klonsky et al., 2014). NSSI takes many forms including cutting, scratching, piercing, or burning the skin; preventing wounds from healing; and head banging (Favazza, 2011). The functions of NSSI vary considerably between individuals; however, commonly endorsed reasons are emotion regulation, self-punishment, relief from dissociation, and the communication of psychological pain (Doyle et al., 2017; Edmondson et al., 2016).
NSSI affects individuals across the lifespan, but onset frequently begins in adolescence (Brager-Larsen et al., 2022). Prevalence rates in community samples suggest that approximately one in five individuals report a history of self-injury (Andover, 2014; Giordano et al., 2023). Clinically, NSSI is a frequent presenting concern; 97.9% of licensed clinicians reported working with NSSI at some point during their careers (Giordano et al., 2020). Despite this, counselors often experience anxiety and self-doubt when working with clients who self-injure (Whisenhunt et al., 2014), perhaps in part because of the limited scholarly resources available to guide intervention.
NSSI has historically been linked with impulse control problems, largely because of its association with borderline personality disorder (BPD; Hamza et al., 2015). However, recent meta-analyses examining NSSI and impulsivity have produced mixed findings (Hamza et al., 2015; Liu et al., 2017). One study examined the degree of impulsivity and found that 77% of participants waited an average of 15 minutes or less between NSSI thought and action (Glenn & Klonsky, 2010). A positive relationship was also found between the frequency of NSSI and lack of premeditation and perseverance. However, no differences in inhibitory control function were found between individuals who self-injured and those who did not. Before its recent classification as a condition for further study in the DSM-5 (American Psychiatric Association [APA], 2013), NSSI appeared only once in the manual, as a symptom of BPD.
Undercontrol and Overcontrol
Self-control is a multidimensional construct that encompasses the ability to regulate behavior following social norms, moral standards, and long-term goals (Baumeister & Heatherton, 1996). Self-control has been linked to numerous positive outcomes, including superior academic performance, well-being, and relationships (Hofmann et al., 2014; Tangney et al., 2004). However, although many theorists (e.g., Metcalfe & Mischel, 1999; Tangney et al., 2004) posit that high levels of self-control are invariably advantageous, some have argued that the relationship between self-control and well-being is curvilinear, with both the highest and lowest levels of self-control capacity being maladaptive (Block & Block, 1980; Lynch et al., 2015).
Although research on overcontrol (OC; i.e., the excessive presence of self-control) is limited, maladaptive overcontrol is not new. Block and Block developed a theory that focused on individual differences in impulse control, which varies from undercontrol to overcontrol (Block, 2002; Block & Block, 1980). Undercontrolled (UC) individuals struggle with impulse and emotion regulation, exhibiting spontaneity, impulsivity, emotional variability, disregard for social norms, and indifference to ambiguity. In contrast, overcontrolled individuals excessively inhibit their impulses and expressions, which is characterized by emotional restraint, dependability, high organization, and an unnecessary delay of gratification or denial of pleasure. More recently, Lynch (2018) proposed a transdiagnostic model of disorders of overcontrol in conjunction with the development of Radically Open Dialectical Behavioral Therapy (RO DBT). This model suggests that although overcontrolled individuals often achieve measurable success, they frequently experience pervasive loneliness and psychological distress.
Undercontrolled and Overcontrolled NSSI
NSSI has historically been associated with deficits in impulse control (Glenn & Klonsky, 2010); however, evidence suggests that individuals high in self-control also self-injure (Claes et al., 2012; Hempel et al., 2018). Hempel et al. (2018) found that self-injurious behavior in undercontrolled individuals is typically impulsive, emotionally driven, and may involve others. In contrast, overcontrolled individuals tend to engage in planned, rule-governed, and secretive self-injury. Although this study offers compelling evidence of differing self-injurious behaviors based on undercontrol and overcontrol, further research is needed to fully understand these differences.
Purpose of the Study
Despite extensive research on NSSI, much remains to be understood about this behavior. The inclusion of NSSI as a condition for further study in the latest DSM revision (APA, 2022) underscores the need for more research to refine diagnostic criteria and clinical interventions. Significant research has yet to focus on NSSI within the frameworks of undercontrol and overcontrol. Thus, our study aimed to develop a theory about undercontrolled and overcontrolled self-injury in order to fill existing gaps in the literature and to enhance clinical understanding and treatment. Our research question was: What are the experiences, attitudes, and behaviors related to undercontrolled and overcontrolled self-injury?
Method
We selected a constructivist grounded theory approach, which seeks to offer explanations about a phenomenon from the perspective of those who experience it (Charmaz, 2014). This inductive approach facilitates the construction of a theoretical model that systematically describes processes associated with the phenomenon of interest (Charmaz, 2014) and, therefore, is well-suited to helping counselors understand their clients’ experiences and behaviors (Hays & Singh, 2023). Constructivist methodology holds the ontological position that our world is socially constructed through interactions over time; therefore, the researchers and participants are co-creators of knowledge (Charmaz, 2014).
Researcher Reflexivity
Reflexivity is essential if researchers’ experiences and interpretations influence the grounded theories they construct (Charmaz, 2014). Sara E. Ellison is a White cisgender woman, a doctoral student, and a licensed professional counselor (LPC). She has experience working with clients who self-injure in residential and outpatient settings, which sparked her interest in the differences in undercontrolled and overcontrolled NSSI. This clinical experience and her training in dialectical behavior therapy (DBT) and RO DBT influenced the expectation that UC NSSI would align with characteristics such as impulsivity, emotionality, and openness, and that OC NSSI would align with planning, inhibited emotion, and secretiveness. Jill M. Meyer is a White cisgender woman, a professor and Director of Counselor Education at a CACREP-accredited R1 university, and an LCPC. Her education, training, and clinical experiences are outside of this topic area, positioning her to be objective in the study of NSSI. She approached this research with curiosity about whether OC and UC NSSI would reflect characteristics previously described in the literature on OC and UC.
Julia Whisenhunt is a White, cisgender woman and a professor at a regional comprehensive university with a CACREP-accredited program. She is an LPC and a certified professional counselor supervisor who specializes in crisis intervention and has studied NSSI for approximately 15 years. Based on her work with clients who self-injure and her prior research and scholarship on the topic, she entered with core assumptions about NSSI that may have contributed to her conceptualization of the data. Whisenhunt believes that NSSI most often serves as a coping skill for intense intrapersonal experiences (e.g., self-loathing, despair, anger, fear, shame, anxiety, dissociation) and is best treated through a person-centered approach. Jessica Meléndez Tyler is a Latina cisgender woman and a faculty member at a CACREP-accredited R1 institution. She is a licensed counseling supervisor with 15 years of experience working with at-risk adults in outpatient settings. Tyler’s clinical experiences have deepened her understanding of the complexities of NSSI, driving her commitment to advancing knowledge and interventions in this area. She approached this research with the assumption that UC and OC play a significant role in NSSI and that effective and humanistic therapeutic interventions can improve the quality of life for affected individuals. Our values of empathy, compassion, and a nonjudgmental approach to behaviors that have often been misunderstood by the public guided our interpretation of the data, aiming to view NSSI through a lens of human complexity rather than pathology.
This research was completed as a dissertation study with Ellison receiving support and guidance from the other authors throughout the research process. Ellison conducted intensive interviews and coding, with Meyer and Whisenhunt advising and supporting the consideration of multiple perspectives. We met eight times during data collection and analysis, during which we reviewed emerging codes, participant narratives, and developing theory. We also engaged in reflexivity exercises and triangulated the findings with existing NSSI scholarship. Tyler assisted with study conceptualization and manuscript development.
Participants and Procedures
After obtaining institutional review board approval, we used purposeful criterion sampling and theoretical sampling to recruit participants (Timonen et al., 2018). Selection criteria included adults who had self-injured five or more times in their lifetime and self-identified as undercontrolled or overcontrolled. Although qualitative research on NSSI often includes individuals with any NSSI experience (e.g., Hambleton et al., 2022), we chose to recruit those with significant NSSI histories to better understand their behavioral, emotional, and cognitive patterns. This is consistent with previous qualitative research including those who have self-injured five to six times in their lifetime (da Cunha Lewin et al., 2024; Kruzan & Whitlock, 2019).
It is recommended that researchers screen participants for vulnerabilities and balance the need for rich data with potential harm when asking sensitive questions (Hays & Singh, 2023); therefore, we conducted a literature review to assess the potential iatrogenic effects and benefits related to participating in interviews broaching NSSI. Researchers have viewed self-injury in the context of the transtheoretical stages of change model and suggested that individuals enter the termination stage after 3 years of abstinence from NSSI behavior (Kruzan et al., 2020). Previous studies (Muehlenkamp et al., 2015; Whitlock et al., 2013) have indicated that participating in detailed NSSI research did not have significant adverse effects; however, to minimize risk, participant eligibility for the study was based on the absence of any current suicidal ideation and no self-injury in the past 3 years.
In order to reach individuals with meaningful self-injury experience, we posted a recruitment flyer in four Facebook and Reddit support groups related to self-injury. We also emailed calls for participation to experts in the field and shared them on listservs, including Counselor Education and Supervision Network, Georgia Therapist Network, and Radically Open DBT Listserv. Participants received a $25 e-gift card as compensation for their time and contributions.
The 20 study participants all self-identified as undercontrolled (UC; n = 10, 50%) or overcontrolled (OC; n = 10; 50%) as described by Block and Block (1980). Most participants identified as White or Caucasian (n = 14, 70%), with three identifying as Multi-Racial (15%), two identifying as African American and/or Black (10%), and one identifying as Hispanic or Latino/a/x (5%). Likewise, most participants identified as women (n = 18, 90%), with one identifying as a nonbinary woman (5%) and one identifying as a man (5%). Participants ranged in age from 18 to 43, with the mean age being 29.4. The participants lived in various geographic regions, with the most common region being the South (n = 12, 60%), followed by the Midwest (n = 4, 20%), Northeast (n = 2, 10%), and West (n = 2, 10%). We ceased recruiting participants once we achieved comprehensive coverage of emerging categories and new data no longer provided theoretical insights (Charmaz, 2014).
Data Collection
After identifying eligible participants via a screening and demographic questionnaire, Ellison conducted intensive, semi-structured Zoom interviews, each lasting about 60 minutes. The researchers developed the interview protocol after reviewing current qualitative literature and assessment measures on NSSI and consulting with two NSSI subject matter experts with significant qualitative research experience (see Appendix for complete interview protocol). Intensive interviewing relies on the practice of following up on unanticipated areas of inquiry prompted by emerging data (Timonen et al., 2018); therefore, after several participants mentioned their reactions to NSSI in peers or media representations, a question related to perception of others’ NSSI was integrated into subsequent interviews. Participants chose pseudonyms in order to protect their identities; all interviews were audio-recorded and transcribed. Participants were then invited to review their transcripts and make any revisions, redactions, or additions to ensure the accuracy of their voices and experiences.
Data Analysis
Ellison conducted initial coding by labeling data segments to summarize and categorize them. Transcripts were repeatedly read and analyzed as new data were collected to identify similarities and differences in participant narratives. Focused coding then aimed to refine the most salient codes into categories and themes in order to develop a larger theory (Charmaz, 2014). During this phase, Ellison condensed the 38 initial codes into concise descriptions encapsulating participants’ narratives, resulting in 15 themes that explained the relationships between findings. This process moved the analysis from descriptive to conceptual, guiding theory development (Charmaz, 2014). Ellison, Meyer, and Whisenhunt met multiple times to review the developing codebook, connect data, and clarify theory development.
Constant comparative methods (Glaser & Strauss, 1967) were used throughout coding to identify patterns and to ground the theory in participant narratives. Memo writing recorded analytic ideas for later follow-up. Data and codes were organized using Dedoose, a HIPAA-compliant, password-protected online qualitative software. After reaching theoretical saturation we conducted member checks by emailing participants a summary of themes and categories to solicit feedback. All 20 participants confirmed that the emerging theory aligned with their experiences.
Trustworthiness Strategies
Several strategies were employed to enhance rigor and mitigate methodological limitations in this qualitative study. Participant perspectives and the investigated phenomenon’s authenticity are crucial for the study’s validity (Denzin et al., 2023). Member checking was consistently used during data collection and analysis, enabling participants to confirm the relevance of findings to their experiences. Follow-up questions were integrated into interviews to clarify participant responses (Hays & Singh, 2023) and participants reviewed their interview transcripts and initial findings to provide feedback (Charmaz, 2014). Five participants contributed additional insights, enriching the theoretical framework with their unique perspectives. Researcher reflexivity was employed to acknowledge personal beliefs, values, and biases that might influence data interpretation (Hays & Singh, 2023), addressing reactions to participants, insights into potential findings, and adjustments made to the research process.
Findings
The findings of this grounded theory analysis describe the experiences, attitudes, and behaviors related to OC and UC NSSI, including the processes that can facilitate individuals switching profiles and the processes that lead to the cessation of self-injurious behavior.
OC NSSI
Restrained
OC NSSI was associated with high levels of restraint, which allowed participants to mask negative emotions, delay self-injury, and moderate how deeply they cut. Motivated by the highly private nature of OC NSSI, participants often postponed their self-injury for several hours or more to keep it hidden. This time was frequently used to plan when, where, and how self-injury might occur. Emma described this:
There were definitely times where maybe something would happen like at school. Or somewhere out in public or something like that. Where I knew that . . . because I was extremely secretive about what I was doing, that I maybe thought, “well, later I might go home and do that.” I can’t remember ever thinking to myself, “well, I need to go home right now and cut,” you know? That was never crossing my mind.
Participants also used restraint during the behavior, cutting deeply enough to feel relief but not so severely that it resulted in medical attention or attention from others. Jenny shared:
When I was cutting . . . I had to really pay attention. Really focus, laser focus, to not do something wrong or not cause more grievous harm or also to sort of maintain some pain, but maybe not too much pain, not go too deep.
Participants expressed a sense of pride in their ability to utilize restraint related to OC NSSI, which contributed to their sense of identity and differentiated their behavior from impulsive conceptualizations of self-injury.
Highly Private
Participants were highly private about their OC NSSI, prompting them to avoid disclosure experiences, take great care to hide injuries and scars, and avoid medical attention. This desire to conceal their self-injury was often motivated by maintaining a specific image or not burdening others. Emma shared, “I didn’t want to be a burden to anyone or my pain to be a burden to anyone. And so that was my worst nightmare, for someone to know what was going on.” OC NSSI was seen as deeply personal and carried out solely for the benefit of participants. The highly private nature of OC NSSI influenced the location of participants’ self-injury as well as rules that would support keeping it hidden, as Madeline described:
I never . . . very rarely cut on my arms or like even my legs because I [was] training for triathlons and was swimming. And so a lot of it was like on my breasts, on like my pelvic area where it would never be seen.
The avoidance of medical care meant that some participants took responsibility for caring for severe wounds independently. Phoenix described learning to suture her wounds on YouTube. Rex instituted a disinfecting process after a cut on her leg became severely infected: “I didn’t want to end up in the hospital having to have somebody ask a question about [self-injury].” Even after the cessation of NSSI, participants were often reluctant to discuss the behavior. Jenny disclosed that her participation in this study represented more discussion about her self-injury than all her other disclosures combined. The private nature of participants’ OC NSSI made them less likely to seek help, including mental health care.
Guided by Rules and Ritual
Participants describing OC NSSI spoke of rules that dictated their use of specific tools, number of cuts, and locations on the body. Often, these rules were based on a compensatory approach to self-injury in which participants responded to specific wrongdoings or perceived failures with distinct approaches to self-punishment. These rules provided the scaffolding for behavior that became ritualistic. Participants described a structured, disciplined approach to self-injury that was often motivated by upholding established routines rather than emotional dysregulation or NSSI urges. Katie shared that her self-injury occurred nightly around the same time and in the same location: “There were nights where I didn’t really feel like I had like a lot of emotions. And it was more of that secret part of it, where I was keeping a routine. Like, ‘Well, time to go do this.’” Madeline adhered rigidly to the rules and ritual she had established for herself: “I’m not gonna stop. If I’ve decided this is gonna happen 113 times, I’m doing 113. Like, regardless of if I decide halfway through, I don’t wanna keep doing this.”
Participants also described ritualized aftercare, often involving an organized medical supply kit, which became a meaningful part of the self-injury process. In some cases this also involved photographing, writing about, or otherwise documenting their wounds. Phoenix shared that she “always stitched it up, or whatever. In the moment, it was something that was very destructive. But afterwards, it was always taken care of . . . maybe in a way, that was a way of kind of taking care of myself.” The rules and rituals associated with participants’ OC NSSI created order and structure in their lives. They imbued the behavior with meaning that elevated it beyond a simple emotion regulation tool.
Perception of Others’ NSSI as Inferior
Participants describing OC NSSI often expressed feeling as though their self-injury was superior to others’ and were highly judgmental of NSSI that they viewed as impulsive or not intentionally hidden. They eschewed the idea of their own NSSI as attention-seeking and felt a sense of pride in their ability to control their impulses and affect and meticulously hide their behavior. Katie shared, “I think I felt very judgmental of [others who self-injured], like, ‘How come you’re doing this to yourself and then sharing it to everybody?’ Like, ‘I can’t believe you’re using this to get attention and stuff like that.’”
These participants used words such as “correct,” “pious,” “better,” and “right” to describe the way they self-injured, positioning themselves as morally superior and intrinsically dissimilar from others who approached the behavior differently. Emma described this:
Pride is a strange word to describe it, but it was almost sort of like being more pious. It was like . . . I’m holding this big secret. I’m doing this thing, and that’s the way it should be. So I felt like I was doing it correctly.
Participants viewed their OC NSSI as different from what they saw around them, which contributed to both a sense of isolation and a feeling of pride.
Cessation—Loss of Utility and Defined Decision to Stop
Cessation of OC NSSI often occurred when the behavior lost its utility and followed a defined decision to stop. This pragmatic approach meant that once the benefits of self-injury waned, participants saw no reason to continue to engage with it, as Katie described:
I feel like I achieved what I wanted to achieve and now I don’t feel like doing it anymore . . . I remember going into therapy afterwards and thinking, “I don’t know why I’m here because like I don’t even feel these urges anymore. So . . . there’s no point.”
Although cessation experiences sometimes included counseling or other interventions, they often occurred independently, consistent with the highly private nature of OC NSSI.
Scaffolded by their ability to exercise restraint, participants rarely went back on their decision or experienced a lengthy cessation process. Katie stated, “I think that was another part of the control. Like I get to decide when I do this and how I do this and when I stop and stuff like that.” Lauri also identified a defined ending of her self-injurious behavior:
I actually got to a point where I was like, “Okay, I’m in my 30s now. This has like, you know, got to stop. Like, this is not okay.” But I actually went and got a tattoo as a marker that I’m not doing this anymore, and I haven’t.
The resoluteness with which they committed to their decision to stop often felt more salient than any distress they experienced because of cessation.
UC NSSI
Impulsive
UC NSSI was described as occurring in an impulsive and unplanned manner. Participants described an urgency to their self-injurious thoughts that motivated them to seek immediate relief, often within minutes of the decision to self-injure. Lauri stated that when she had an urge to self-injure, “It was kind of like a panic, like trying to get to it as soon as possible to get relief.” To facilitate this, some participants always carried self-injury tools with them. Others used whatever they could find nearby, even it was not their preferred instrument. If these participants delayed their self-injury, it was due to seeking favorable circumstances rather than planning or premeditation. Amy shared: “There wasn’t a premeditated like separate razor blade or anything. It was just, I knew where and when I could do it. And so if I got overwhelmed, I might go take a shower or something.” This impulsiveness sometimes contributed to disclosure experiences because participants could not inhibit their self-injury urges until they reached a private space, or their hastiness contributed to others’ suspicions.
Disclosed Despite Secrecy
UC NSSI was often disclosed despite participants’ desire for secrecy. Participants’ inability to delay their NSSI behavior or mask their emotions sometimes contributed to self-injuring with others present or in manners that were more likely to be discovered. Additionally, participants described conflicting feelings related to disclosure in which they often desired for others to know about their NSSI while simultaneously experiencing shame or embarrassment about the behavior. Rose described wanting to cut in places that could be covered, but also shared that she didn’t hide her self-injury from her friends:
I had a couple of really close friends at college, and I told one of them pretty early on, and that was voluntary . . . I don’t remember how I told the others or if I just said, “it’s okay if you tell the others.” But eventually, my friend group knew.
Lola described hiding her self-injury, but not so deliberately that it didn’t raise people’s suspicions: “I always wore long sleeves, which definitely I guess I could say my parents felt a little bit suspicious of when it was summertime and stuff.” Eventually, Lola’s mom became so suspicious that “she asked to look, and so I showed her, and she found out, and we had a conversation about it and everything.” Jane also shared conflicting thoughts related to disclosure. On one hand, she shared, “I would cut my arms mostly. And that was like a, ‘hey, I’m doing this,’ kind of thing.” At the same time, she remembered thinking:
This is embarrassing. I don’t really want people to know or ask me about it. But it was also like, in a place where like, sometimes I’d be in a t-shirt. So sometimes you would see it. Or sometimes people would notice.
Participants’ ambivalence about disclosure often resulted in inconsistent or disorganized concealment behaviors, making the discovery of their NSSI by others more likely.
Guided by Emotion
Emotion influenced when, where, and how UC NSSI occurred. Participants reported being highly responsive to their mood states and experiencing self-injury as a potent strategy to cope with dysregulation. Because they were typically unable or unwilling to inhibit their impulses, self-injurious behavior often occurred at the peak of emotional distress. Rose reported that “any negative feeling, but especially like guilt or regret [or] shame” might trigger an episode of self-injury, “so it was very much an emotional regulator.”
Pacey described the emotional intensity when he would self-injure: “Definitely [self-injury would occur] at the top. Sometimes I remember crying really hard when it was happening, or feeling so anxious that I was lightheaded. And the cutting would help bring that emotion down.” This connection between emotionality and UC NSSI meant that participants more frequently conceptualized their triggers as interpersonal, resulting from interactions that precipitated emotional distress.
Perception of Others’ NSSI as Superior or Relatable
If participants encountered peers that self-injured or media representations of NSSI, their view was often that others’ NSSI was superior or relatable. Participants sometimes described feeling that others’ self-injury was “cooler,” “better,” “brave,” or more “impactful” than their own and endorsed a desire to emulate this. Jane shared:
There was definitely a period of time where I would see people who maybe were self-injuring in a way that was more aggressive than I was doing it and definitely had some inferiority complex going on like, oh . . . mine’s not impactful . . . I felt like an imposter.
When Pacey joined online support groups, he “felt a lot of similarities to their stories . . . And it was nice to know that I wasn’t alone.” Even when participants identified a misalignment between others’ self-injurious behaviors and their own, they typically remained nonjudgmental and assumed that others were doing the best they could. Rose shared:
In the books I read, it was portrayed really sympathetically. Like, they’re struggling, and so are the friends [I knew that self-injured]. But somehow still, I got that idea of people do it for attention. But my personal experience from books and friends was just like, they’re having a hard time, and that’s the only way they can figure it out.
Participants’ view of others’ NSSI as superior or relatable influenced their willingness to engage in conversations with others who self-injured, further supporting their capacity to seek and receive help.
Cessation—Interpersonal Influence and Protracted Process of Stopping
Interpersonal influence (e.g., therapy or pressure from peers or family) contributed to the cessation of UC NSSI. Jasmine described the support from her inner circle as essential to her self-injury cessation. “They would encourage me to call one of them and just have them come over or have me go to the restroom or outside near a tree and just talk through what my emotions were telling me.” Amy also leaned on support from friends:
Having that friend that knew about it from freshman year that I lived with was also a help in not doing it again because I could go literally right next door to her room and kind of talk about how I was feeling for a second and sit on her floor and just let that feeling pass.
Rose shared that seeing a counselor twice weekly supported her in decreasing and ultimately stopping NSSI. Because participants frequently had already disclosed their UC NSSI, interpersonal support was more likely to be available and, therefore, influential to cessation.
Participants also highlighted the lengthy process of stopping their self-injury. Tricia recalled gradually working on controlling her emotions in other ways:
It wasn’t something that I stopped immediately because, like I said, I tried to work on my emotions. I tried to control my anger. I went back to it and almost went back to it a lot of times. I tried to distract myself from the cause of the pain. . . . It wasn’t a fast process. It was a gradual process.
Participants experiencing a protracted cessation process did not typically memorialize it or assign specific meaning to the final experience.
Processes Supporting Participants Switching Profiles
UC to OC NSSI: Aging and Feedback
Participants reported that getting older and receiving negative feedback influenced their transition from UC NSSI to OC NSSI. Jane shared her feeling that “when you’re in your teens, a lot of people are doing weird self-harm shit. . . . by the time you’re in your 20s, if people see something on your arm, they’re like, ‘what the fuck is wrong with you?’” Shane echoed this: “It was easier to hide when I got older because I understood—cognitively, I was like, ‘well, this isn’t really healthy or appropriate.’ But I still did it.” As participants encountered criticism or judgment related to self-injury, they often became more secretive, restrained, or ritualistic in their behaviors. Roxanne shared how feedback influenced the way she engaged with self-injury:
I had a friend notice, and she told the teacher and I was really embarrassed. And then my grandmother found out and she was really mad. And so I realized that I needed to do a better job hiding it. And so that’s why I moved locations, because I really didn’t want anybody to know. I was embarrassed by it. But it did make me feel a lot better. And so I wanted to keep doing it.
When participants transitioned from a UC NSSI profile to an OC NSSI profile, they typically continued to self-injure in this manner until cessation.
OC to UC NSSI: Intense Interpersonal Distress, Fear, and Shame
Participants described experiences of intense interpersonal distress as a salient factor in their transition from OC NSSI to UC NSSI. During relational conflict that resulted in extreme dysregulation, participants reported losing the ability to moderate their emotions or how severely or impulsively they self-injured. Rex shared an experience of UC NSSI that occurred in the context of an abusive relationship, describing it as a departure from her previous self-injury, which was private, superficial, and very controlled:
and she kept on yelling and yelling and then I did it in front of her and the fat started bleeding out of my arm. . . . It was like scarier and felt way more out of control than anything like I had ever experienced as far as self-harm.
Participants’ impulsivity and emotionality in these moments meant that they might self-injure in the presence of others or reach for tools they didn’t normally use, resulting in wounds that were more severe than they normally experienced.
When participants who typically self-injured in a restrained, private manner experienced UC NSSI, the result was acute feelings of fear and shame. Perhaps because they had previously held judgment of self-injury that occurred impulsively and publicly, self-judgment often occurred in the wake of a transition to UC NSSI. Olive described the fear they felt after the last time they self-injured, which resulted in 17 stitches:
I was having nightmares and flashbacks for three months afterwards. So it was traumatic for me to experience, and I scared myself. I didn’t know that I could do that to myself. I didn’t know that I was capable of causing that kind of harm, and I guess it made me realize how dangerous it was for me to be doing what I was doing because when I actually did it I had a total loss of control in that moment.
These feelings of fear and shame felt by participants, coupled with the loss of equilibrium related to their NSSI identity, prompted them to reconsider the role of NSSI in their lives. Often, this episode of UC NSSI represented the last time they self-injured.
The Theory of Overcontrolled and Undercontrolled Self-Injury, illustrated in Figure 1, was developed based on participant narratives and feedback to represent the experiences, attitudes, and behaviors associated with OC and UC NSSI. Participants were asked to self-identify as UC or OC; however, this classification did not consistently align with their profile of self-injury. For example, three participants identified that their NSSI behavior was markedly different than their behavior in the rest of their lives. Additionally, several participants described transitioning from one profile to another at some point during their self-injury. As a result of this unexpected finding, we categorized participant NSSI based on their descriptions of their self-injurious experiences, attitudes, and behaviors rather than their self-identified personality typology.
Figure 1
Theory of Overcontrolled and Undercontrolled Self-Injury
Discussion
This study provides insight into how self-control influences individuals’ experiences of NSSI. The data identified two distinct profiles, which is consistent with prior research indicating the ability to differentiate NSSI behavior based on its occurrence in OC or UC contexts (Hempel et al., 2018). OC NSSI was characterized as restrained, private, and rule-guided, aligning with previous conceptualizations of OC linked to impulse inhibition, high distress tolerance, and rigid behavioral patterns (Block, 2022; Block & Block, 1980; Lynch et al., 2015). Similarly, UC NSSI was described as impulsive, disclosed despite secrecy, and emotion-driven, consistent with literature highlighting heightened emotional fluctuations, low distress tolerance (Block, 2002), and higher levels of openness and expressiveness (Gilmartin, 2024).
Although a desire for secrecy was reported in both OC and UC NSSI, the commitment and dedication to maintaining this privacy varied between groups. This study’s findings differ slightly from those of Hempel et al. (2018), who described UC NSSI as public, lacking nuance regarding participants’ internal conflicts. Participants’ dissonance regarding disclosure may be viewed through a lens of dialectics. Linehan (1993) described BPD, a disorder of UC, as a “dialectical failure” in which individuals vacillate between contradictory viewpoints, rendering their behavior inconsistent and confusing. OC, on the other hand, has been associated with maladaptive perfectionism (Lynch et al., 2015), in which individuals avoid vulnerability to maintain an image of flawless performance (Dunkley et al., 2003). Those striving to appear problem-free may perceive their self-injury as a sign that they are flawed or weak and thus go to great lengths to conceal it. Because both groups describe their NSSI as secretive, further exploration of disclosure patterns is essential to facilitate deeper understanding.
An unexpected finding was that participants’ perceptions of others’ NSSI differed based on whether they engaged in UC or OC NSSI. One explanation for the association between OC NSSI and a perception of others as inferior may lie in a phenomenon described by Lynch (2018) as “the enigma predicament.” The enigma predicament is a self-protective stance in which OC individuals believe they are fundamentally different or more complex than others. This attitude maintains social isolation, aloofness, and a feeling of being misunderstood. Cultural emphasis on self-control may bolster beliefs of superiority among these individuals, fostering a secret sense of pride.
No existing literature was found that explored the judgments of individuals who self-injure related to others’ NSSI; however, viewing these findings through the lens of social norms offers context. OC individuals are sensitive to social pressures and conformity, whereas UC individuals are less concerned with societal norms (Block, 2002). Individuals experiencing UC NSSI may be more likely to disregard prescriptive norms for self-presentation, facilitating empathy or admiration for those openly displaying their NSSI. Those experiencing OC NSSI, which is typically a well-kept secret, may be unlikely to encounter others engaging in NSSI in a like manner.
Another novel finding lies in the shifts participants described in their self-injury profile as a direct result of specific experiences, such as aging and feedback. Although no existing literature was found that examined this phenomenon, UC typically peaks in early to middle adolescence (Hasking & Claes, 2020), suggesting that aging may influence a transition from impulsive to more restrained NSSI for some individuals. It is also plausible that individuals whose self-injury was disclosed (i.e., UC NSSI) would receive more negative feedback than those whose self-injury remained concealed (i.e., OC NSSI). Participants who reported switching from OC to UC NSSI attributed this change to experiences of intense interpersonal distress that appeared to eclipse their high capacity for restraint and control. Lynch (2018) described this phenomenon as “emotional leakage,” in which OC individuals temporarily lose the ability to inhibit their impulses, leading to intense emotional outbursts followed by feelings of shame and self-criticism.
Implications for Counselors
The emergent theory in this study creates a new theoretical model that may provide valuable implications for clinical practice. The identification of two distinct profiles of NSSI supports previous research indicating that individuals with both low and high levels of self-control may engage in self-injurious behavior (Hempel et al., 2018). The current proposed criteria for NSSI disorder, listed in Section III of the DSM-5-TR (APA, 2022) as a condition for further study, would identify both OC and UC NSSI as conceptualized in this study. For instance, criterion C specifies that self-injury may involve “a period of preoccupation with the intended behavior that is difficult to control” or “frequent thoughts about self-injury, even if not acted upon” (p. 923). This expands previous views of NSSI by recognizing behaviors that involve greater restraint alongside those driven by impulse inhibition failures.
Knowing this, counselors may benefit from conducting thorough assessments to accurately diagnose and differentiate between OC and UC NSSI. This can involve using clinical interviews, standardized assessments, and behavioral observations to evaluate clients’ impulse control and emotional regulation abilities. Recommended measures include the Assessing Styles of Coping: Word-Pair Checklist (Lynch, 2018) for adults and the Youth Over- and Under-Control Screening Measure (Lenz et al., 2021) for children and adolescents. To assess OC and UC self-injury specifically, including questions in clinical interviews that evaluate the dimensions explored in this study may be helpful. Clinicians can also inquire specifically about clients’ NSSI impulsivity and emotionality levels, disclosure and aftercare behaviors, and whether any rules or rituals inform the behavior. Questions such as, “When you self-injure, do you tell anyone about it before or afterward?” and “Do you have any rules about when, where, or how you self-injure?” may assist clinicians in developing a deeper understanding of the processes driving the behavior, thereby informing the use of congruent therapeutic interventions.
Participants in this study highlighted distinct processes influencing their NSSI behaviors and cessation, emphasizing the need for tailored treatment approaches based on whether NSSI occurs in an OC or UC context. Traditional therapeutic approaches to treating self-injury, such as DBT (Linehan, 1993) and emotional regulation group therapy (Andover & Morris, 2014), which focus on improving emotional regulation and distress tolerance, may need to be adapted or supplemented to address specific vulnerabilities and underlying mechanisms related to OC NSSI. Interventions targeting UC NSSI should emphasize enhancing inhibitory control and distress tolerance while reducing emotional reactivity. Conversely, interventions treating OC NSSI should aim to relax excessive inhibitory control and rigidity while increasing emotional expressiveness and openness. RO DBT, which was developed specifically to treat disorders of OC by targeting deficits related to excessive inhibitory control (Lynch et al., 2015), represents a promising approach for these clients.
Understanding participants’ perceptions of others’ NSSI behaviors also holds implications for social contagion (Conigliaro & Ward-Ciesielski, 2023). Previous research has implicated identifying or relating with others who self-injure (Whitlock et al., 2009) and a higher need to belong (Conigliaro & Ward-Ciesielski, 2023) as factors increasing vulnerability to social contagion. Because UC NSSI was associated with a perception of others’ NSSI as superior or relatable, individuals exhibiting this self-injury profile may be more vulnerable to the effects of social contagion. Counselors should be aware of these dynamics when formulating interventions.
Lastly, counselors can benefit from considering how the enigma predicament may negatively impact the therapeutic relationship with OC clients who may believe that they are so complex or unique that they will invariably be misunderstood (Lynch, 2018). This may explain why study participants experiencing OC NSSI sometimes found therapy unrewarding or unhelpful, particularly if counselors generalized about self-injury in a way that felt incongruous with their experiences. Knowing this, counselors should aim to set aside their assumptions about self-injury and allow the client to educate them on their experience.
Care should also be taken when asserting that OC NSSI behavior is normal, common, or understandable. Although this might typically be viewed as a positive intervention (i.e., normalizing the behavior), such expressions may cause alliance ruptures in this population (Lynch, 2018). Acknowledging these unique perspectives and avoiding assumptions about the normalcy or commonality of NSSI behaviors can help maintain therapeutic rapport and prevent alliance ruptures. By integrating these implications into clinical practice, counselors can enhance their ability to effectively assess, conceptualize, and intervene with UC and OC NSSI, ultimately promoting resilience and improved psychological well-being.
Limitations and Suggestions for Future Research
Several limitations must be acknowledged in order to interpret this study’s findings. First, because of the absence of validated measures of UC and OC, participants self-identified based on Block and Block’s (1980) conceptualization of these terms. Knowing the challenges associated with the clinical assessment of OC (Hempel et al., 2018) and the subjective nature of self-assessment, it is reasonable to assume that some participants may have self-identified in ways that are incongruent with established criteria for UC and OC. Future studies aimed at the development of instruments capable of effectively measuring and differentiating between OC and UC NSSI would aid mental health and medical professionals in congruent conceptualization and intervention for NSSI. They would also pave the way for quantitative exploration of UC and OC NSSI, potentially fostering greater knowledge, understanding, and generalizability.
The sample in this study was composed predominantly of White women, limiting its ability to encompass a diversity of experiences. It is possible that a more diverse sample would have generated different results. Future studies should intentionally strive to incorporate more diverse samples, specifically focusing on amplifying the voices and experiences of gender-diverse individuals, people of color, and men. Care should be taken in generalizing the results of this analysis, especially in groups underrepresented in sampling. Additionally, participants in this study had not self-injured in the last 3 years, which may have allowed for a greater degree of cognitive processing related to their experiences. Future studies focusing on current self-injurious experiences are needed to support the development of effective interventions in this population.
Finally, this study’s qualitative design has inherent limitations despite efforts to ensure credibility and trustworthiness. The semi-structured interview method used may influence participant responses through question framing, wording, and presentation. Additionally, the research team’s perspective inevitably influences the interpretation of findings, allowing for alternative interpretations by different research teams.
Conclusion
The constructivist grounded theory findings enrich our initial grasp of how self-control influences NSSI experiences, attitudes, and behaviors, offering significant implications for mental health research and clinical practice. Future efforts should focus on translating these insights into evidence-based assessments and interventions that acknowledge individuals’ attitudes, motivations, and vulnerabilities associated with NSSI, aiming to effectively enhance resilience and well-being.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Appendix
Interview Protocol
- Please give me a brief timeline of your experiences with self-injury over the course of your lifetime.
Alternate wording:
I’d like to ask you to think back to the first time you self-injured. Could I ask you to describe what led to that moment?
- Where on your body did you typically self-injure?
- Have you ever hurt yourself during self-injury to the extent that you needed medical assistance, even if you did not receive it?
Follow-up questions:
a. What was the experience of seeking medical help like for you?
b. How did you manage treating the injury without medical professionals?
- What has your experience been with disclosing your self-injury to others?
Follow-up questions:
a. Who are the people in your life that are aware that you have self-injured?
b. Did you choose to tell those people about your self-injury or did they find out in some other way?
c. What were people’s responses when they found out that you had self-injured?
d. What influenced your decision to disclose or not disclose your self-injury?
- Please describe the purpose of your self-injury?
Alternate wording:
How did your self-injury influence your mental health? Relationships?
What did self-injury offer you?
- When you self-injured, to what extent did you plan how, when, or where you were going to do it in advance?
Follow-up questions:
a. How would you describe the period of time between thinking about how or when you were going to self-injure and the self-injurious behavior itself?
b. How long was the period of time, generally, between the thought and the behavior?
- Did you have any rules about when, where, or how you self-injured? If so, could I ask you to describe them to me?
- If you think about your level of distress or emotionality as a wave with a peak where the emotion is most intense, when did your self-injury typically occur along that continuum?
- If a close friend or family member had seen you in the moments before you self-injured, to what extent would they have suspected that you were in distress?
Follow-up question:
What factors would have influenced their idea that you were/were not in distress?
- How would you describe the experiences that led you to stop self-injuring?
Is there anything else you would like to add about your experiences that we haven’t touched on?
Sara E. Ellison, PhD, NCC, ACS, LPC, is adjunct faculty at Auburn University and the University of West Georgia. Jill M. Meyer, PhD, LPCP, CRC, is a professor and Director of Counselor Education at Auburn University. Julia Whisenhunt, PhD, NCC, LPC, CPCS, is a professor, assistant chair, and program director at the University of West Georgia. Jessica Meléndez Tyler, PhD, NCC, BC-TMH, LPC-S, is an associate professor at Vanderbilt University. Correspondence may be addressed to Sara E. Ellison, 3084 Haley Center, Auburn, AL 36849, szm0194@auburn.edu.
