Dec 11, 2017 | Book Reviews
Niklas Törneke, in his book, Metaphor in Practice, provides a very helpful guide to understanding and using metaphors in mental health counseling. The book is divided into two primary sections. The first section reviews research on metaphors and establishes support for metaphors being appropriate for counseling. The second section describes how metaphors are structured and can be used to support the counseling goals of acceptance and commitment therapy (ACT). For those only interested in the practical use of metaphors, it is possible to skip section one. However, both sections contain valuable information.
In part one of the book, Törneke delves into linguistic and psychological research into metaphors, connecting those findings to the theory underlying ACT, namely, relational frame theory (RFT). RFT puts forward the view that the process of developing language and the ability to function in the world involves perceiving and internalizing relationships. ACT was developed from RFT and contains a foundational belief that the internalized, maladaptive relating of thoughts, emotions, behaviors, and events is the basis for most mental illness. The therapeutic approach in ACT is to change those internalized and maladaptive relationships. Metaphors are highlighted as a particularly helpful way of shifting those relationships because the function of metaphors is to expand understanding by relating something that needs to be better understood, the target, to something else more easily understood, the source. Metaphors are presented as a tool to guide the transformation of maladaptive relationships into adaptive ones. This first section, in addition to expanding understanding of metaphors, provides an informative introduction to RFT and the therapeutic approach that grew out of it, ACT.
In part two of Metaphor in Practice, the book shifts from theoretical to practical. It highlights three stages in the behavioral change process of ACT: establishing the relationship between behaviors (with thoughts and emotions understood as behaviors) and their problematic consequences; developing an internal ability to observe one’s own internal processes (e.g., thoughts, emotions, physical sensations); and helping the client clarify what is important in life and making steps toward what is important. For each of those stages, examples are given of how metaphors can support the goals of the stage. In each of the examples, the structure of the metaphor is dissected to reinforce an understanding of its constituent parts along with its purpose. In addition to verbal metaphors, experiential metaphors, metaphors in which the source is demonstrated through physical exercises, are described with examples, further expanding the reader’s understanding of what may be possible with metaphoric interventions. The organization of metaphor structure and the connection of metaphors to ACT stages and creative interventions provide a clear guide to using metaphors in practice, especially as presented through many well-written and detailed examples.
Metaphor in Practice is a book that is approachable and user-friendly. It provides excellent examples of metaphor usage that may be easily incorporated into readers’ professional practice. It also provides a foundational understanding of metaphors that will allow readers to adaptively use metaphors for specific therapeutic purposes. From a critical lens, the review of literature support for metaphors in section one is helpful, though simplistic. It creates an awareness of research support but does not deeply explore the breadth of literature or address some research findings, such as those of Bohrn, Altmann, and Jacobs (2012), Citron and Goldberg (2014), Citron, Güsten, Michaelis, and Goldberg (2016), and Fetterman, Bair, Werth, Landkammer, and Robinson (2016), that connect metaphor usage to increased emotional processing and emotional experiencing. The connection to emotion has a direct relevance to metaphors in counseling practice and may have strengthened and expanded the foundation for using metaphors in counseling. Though the research review could be strengthened, it does accomplish its goal of being informative and extracting core information that is beneficial for counselors to know. There is also a strong agenda within the book to connect metaphor findings to RFT and ACT, which may not be of interest to those with different theoretical orientations. The practice portion of the book is well-developed and explained, but it must be noted again that the descriptions of metaphor use are all related to stages in ACT. For those not interested in ACT, this may be a barrier. However, even for those not interested in ACT, the clear descriptions of metaphors make their use adaptable to other theoretical purposes. Therefore, and in summation, I recommend this book for counselors and believe the information contained will be interesting and clinically valuable.
References
Bohrn, I. C., Altmann, U., & Jacobs, A. M. (2012). Looking at the brains behind figurative language—A quantitative meta-analysis of neuroimaging studies on metaphor, idiom, and irony processing. Neuropsychologia, 50, 2669–2683. doi:10.1016/j.neuropsychologia.2012.07.021
Citron, F. M. M., Güsten, J., Michaelis, N., & Goldberg, A. E. (2016). Conventional metaphors in longer passages evoke affective brain response. NeuroImage, 139, 218–230. doi:10.1016/j.neuroimage.2016.06.020
Citron, F. M. M., & Goldberg, A. E. (2014). Metaphorical sentences are more emotionally engaging than their literal counterparts. Journal of Cognitive Neuroscience, 26, 2585–2595. doi:10.1162/jocn
Fetterman, A. K., Bair, J. L., Werth, M., Landkammer, F., & Robinson, M. D. (2016). The scope and consequences of metaphoric thinking: Using individual differences in metaphor usage to understand how metaphor functions. Journal of Personality and Social Psychology, 110, 458–476. doi:10.1037/pspp0000067
Törneke, N. (2017). Metaphor in practice: A professional’s guide to using the science of language in psychotherapy. Oakland, CA: Context Press.
Reviewed by: Alwin Wagener, NCC, The University of North Carolina at Greensboro
The Professional Counselor
tpcjournal.nbcc.org
Dec 4, 2017 | Volume 7 - Issue 4
Joshua D. Smith, Neal D. Gray
This interview is the second in the Lifetime Achievement in Counseling Series at TPC that presents an annual interview with a seminal figure who has attained outstanding achievement in counseling over a career. I am honored to present the interview of Amy King, a school counselor in Mississippi and the first practitioner to be interviewed for this series. I was fortunate to attend Ms. King’s presentation at a national conference and was inspired by her years of work with children, in school systems, and mentoring graduate students. Her contributions to the counseling profession, from classroom guidance and counseling to advocating for school counselors, are noteworthy, and set the bar for other clinicians. Joshua Smith and Dr. Neal Gray graciously accepted the assignment to interview Ms. King. What follows are Ms. King’s reflections on her school counseling career and its impact on her students over two generations.
—J. Scott Hinkle, Editor
Amy King, current clinical site supervisor at the University of Mississippi, has been training master’s-level school counselors since 1999. Ms. King has worked diligently within the public school system since 1993, first as a teacher and then as a school counselor. She has been practicing as a school counselor in Oxford, Mississippi, since 1999, and was honored as the Oxford Middle School Teacher of the Year in that same year. Ms. King’s sustained involvement and dedication to school counseling has helped transform the profession. An ongoing advocate for school counselors in Mississippi, Ms. King has recently contacted legislators regarding the need to educate school officials and to follow the American School Counselor Association’s (ASCA) model for school counselors. Her tireless work continues to advance her profession.
Ms. King is presently enrolled in the counselor education doctoral program at the University of Mississippi. She earned her master’s degree in educational psychology in 1996 and a specialist degree in counselor education in 2008, both from the University of Mississippi. Additionally, she attained certification from the National Board for Certified Counselors in both counseling (NCC) and school counseling (NCSC) in 2008. Ms. King currently serves as an active member in a variety of professional organizations. At the state level, she participates in the Mississippi Counseling Association (MCA), and at the national level, she is actively involved in the American Counseling Association (ACA) and ASCA.
Ms. King’s professional work has included numerous presentations on a variety of topics, including working with children and adults who are experiencing poverty, wellness for school counselors, techniques for using photo therapy with children, and play therapy behavior interventions. Ms. King has presented at both the state and national levels, most recently at the ASCA Conference and the Law and Ethics in Counseling Conference in New Orleans, Louisiana, sponsored by the University of Holy Cross. One of Ms. King’s present endeavors is researching the roles and responsibilities of school counselors as they relate to advocacy within the profession.
In this interview, Ms. King responds to several questions addressing her career: challenges and barriers that school counselors experience, advocacy and social justice within the profession, involvement in professional organizations, and the future development of school counseling. Her shared insights will benefit many.
1. What led you to pursue a degree in counseling compared to other helping professions?
When I was a high school student growing up in Starkville, Mississippi, and the house telephone rang, my father would jokingly ask, “Is the doctor in this evening?” From an early point in my life, I discovered a great deal of joy from communicating with my friends and acting as a peer counselor. My schoolmates often called for words of advice and encouragement. I knew at a pretty young age that I really liked talking with people and helping them solve problems. My parents found my ability to help others amusing and something to be proud of in my character. Both of my parents were involved in service professions. My father was an administrator with Social Security. He would invite strangers going through difficult times out to dinner with our family. He would often tell stories about people who were living in their cars, and he helped them to be able to move into a home. My father always had kind words and a humble attitude regarding all the suffering he witnessed through his work.
My mother was a middle school history teacher. She was the teacher who was willing to take on the difficult students and had an amazing rapport and sense of humor with her class. My parents talked about solving problems and working to help people, so I knew that I wanted to have a career that involved reaching out to others.
I learned to talk at a young age and loved communicating with others. I also have always loved children. I babysat and worked in preschools during high school and college. My undergraduate degree is in education, and I spent the first six years of my adult career teaching junior high school English. I began studying counseling immediately after completing my college degree because my students inspired me to become a counselor. I found myself wanting to help students more than I could as their English teacher. During my undergraduate studies in education, my favorite professor was a counselor educator. Dr. Joe Ray Underwood taught me health education. His ideas regarding wellness were cutting-edge in the 1990s during my tenure as a student at Mississippi State University. I am fascinated with the field of counseling and have been a lifelong learner. In 2008, I pursued a specialist degree in counseling from the University of Mississippi. I am currently enrolled in the doctoral program and hope to be finished in 2018. The opportunity to pursue my doctoral degree is fulfilling a lifelong dream of being a counselor educator. The program has empowered me to improve my work as a school counselor and publish papers regarding good practice; it also has fueled new ideas and techniques to bring to my school counseling.
2. In an article from The Oxford Eagle (November 13, 2015) you mentioned, “Many school counselors face a number of constraints preventing them from having enough time to work with students on a small group or individual basis.” Could you elaborate on this statement, as well as other challenges and barriers that you have experienced as a school counselor?
In 1999, when I first became a school counselor, I was serving as the records clerk and testing coordinator for my middle school. This position required being responsible for 600 records. The clerical work involved with my job at that time made it difficult to accomplish my direct student service hours. Occasionally, I would get “in trouble” for not being quick enough with records, but I always put my students before paperwork. Paper does not suffer, but students do. I advocated for a clerical assistant to help with managing records and convinced the superintendent’s office to allow me to document my time in student-related services. I spoke before the school board, and by 2002, the following school year, I had a full-time clerical assistant. Being able to practice within ASCA’s guidelines is what every school counseling student expects upon graduation. Documenting the actual counseling work is necessary to advocate for best practices in our current professional setting. It is important to not be afraid to speak up regarding the best practices of school counselors. I took the chance to speak up for my profession, and by 2004, each school in our district had a clerical assistant. The assistant made it possible for me to conduct classroom guidance, provide more individual counseling sessions, and even host a career fair.
I have been involved with graduate supervision for the University of Mississippi since 2000. Unfortunately, one common theme for the students who graduate as school counselors and go to work in Mississippi is that they are not able to practice counseling in the manner that they would prefer. Students specifically struggle with paperwork, secretarial duties, administrative duties, and testing responsibilities. The ASCA model for school counselors is not being followed in many schools. ASCA recommends that counselors spend 80% of their time in student-related services; these services include crisis intervention, classroom group guidance, and data interpretation and analysis as part of comprehensive guidance plans (ASCA, 2012). Throughout my career, advocacy for my work as a school counselor has been an important part of creating successful comprehensive guidance services. Working to have a positive relationship with the administration and keeping the lines of communication open are key factors in designing and carrying out a quality program in the school setting. Each week I send a lesson plan to my principal that details my weekly guidance. I include topics for classroom guidance, testing information, and group counseling sessions that I have scheduled on a weekly basis. This helps answer that question, “What is the counselor doing?”
When counselors become overburdened with non–school counseling responsibilities, it is difficult to successfully implement a comprehensive guidance program. Proper communication with stakeholders such as principals, teachers, and parents can be highly beneficial to the work of school counselors. Hosting planning meetings with the principal, as well as the other important stakeholders, can be helpful in terms of executing a successful program. My principal appreciates getting a weekly lesson plan and has visited the classroom when I am conducting classroom guidance. I also have met with teachers to design an overall theme for the school year that structured my guidance lessons and field trips. I enjoyed a partnership with the music teacher and had the opportunity to sing to the veterans in the Mississippi State Veterans Home within my theme for the school year, “A Community of Helpers.”
3. In your view, what can be done, or needs to change, to address these challenges and barriers?
Mississippi legislators have addressed the issue of changing policies within public education. In 2014, State Sen. Gray Tollison wrote a bill for school counselors to go into effect for the 2014–2015 school year. MS Code § 37-9-79 3 specifically states that counselors must graduate from a CACREP-accredited program and design a comprehensive guidance program utilizing data analysis (Mississippi School Counselor Law, 2014). It also requires that school counselors spend 80% of the school day in student-related services following ASCA’s model for school counseling.
The fact that this bill has been passed is not widely known by school administrators or counselors, with the excuse of budget constraints as the rationale for why school counselors are not following the state bill as well as the ASCA National Model. Educating school officials about the state legislation regarding school counselor practice is a mission that I am passionately pursuing within my graduate studies and my public school setting. I am a member of the MCA, and there is an organized group within MCA that marched to the steps of the state capitol when decisions were being made regarding the funding and direction of Mississippi’s educational programs. I have made contact with Sen. Tollison, who wrote the law, to thank him and let him know that I am advocating for the law in my graduate studies and my school setting. My dissertation topic is a qualitative analysis of the work of school counselors in Mississippi and their alignment with the ASCA model.
School administrators need to be educated regarding the importance of following the ASCA model. Test scores are a major concern for administrators; therefore, the connection between allowing the counselor to design and implement a comprehensive guidance program that will help increase test scores is a crucial component in shedding light on the importance of a school counselor’s work. The counselor education department at the University of Mississippi is working closely with the educational leadership department to help future leadership teams within the school setting better understand professional goals within the counseling profession as they relate to student success.
4. When discussing systemic change, how do you view your role as a school counselor and collaborative leader when working with school administrators, teachers, parents, and community members?
My role as a school counselor can only be effective when I practice advocacy as a collaborative leader in working with administrators, teachers, staff, parents, and community members. When practicing advocacy with my principal, I am mindful of involving her as an important stakeholder in my work. I send her a yearly calendar of important components of my guidance curriculum, giving her the opportunity to provide feedback regarding our weekly, monthly, and yearlong goals.
My advice to school counselors regarding their work with administration is to keep striving to educate their school leadership team about their comprehensive guidance plan and to have a weekly, monthly, and yearly plan that is well communicated to the administration. This year my theme is “A Community of Helpers.” We visit the State Veterans Home, the local retirement community, the recycling center, and the animal shelter with the overall theme of helping people, our Earth, and animals. I practice advocacy with my teachers by teaching guidance lessons in the classroom and supervising lunch duty. This allows me opportunities to build connections with students. In addition, I partner with school administration and teachers to design a master schedule that best meets students’ needs. This will ensure that the students’ placements are suited for their personal, social, and academic development. I am currently advocating for the teachers to have a lunch break next year because they currently do not have one.
I have had the pleasure of working in the same community for the past 20 years, which has helped my working relationship with parents tremendously. I am currently employed in the elementary setting, which means I have taught or counseled many of the parents at my school. It has been beautiful to see the second generation of families that I have known and loved for my entire career. I view the students as future adult members of the community where I live, and I want to help support and make each member a productive part of society. I often recognize that a current student in my school looks like a former student that I taught or counseled, and I will then discover that the mother or father was one of my former students! I have been so fortunate to have two generations of families within my career. I am able to praise parents for doing a good job with their children and also offer guidance and suggestions when appropriate.
5. School counselors are often relied upon to be political advocates for students. Over the years what has been your experience as an advocate for issues such as social reform, educational policy, administrative functions, and multicultural issues? How can school counselors become more active in advocating for students?
For an example, a few years ago my students faced the possibility of being required to wear school uniforms. The majority of the students were upset and did not want to wear uniforms. I organized a meeting with the student council and the school board so the students could present research about why uniforms would not work well in our school. The board ended up voting against the uniforms, and the students felt vindicated in advocating for themselves, with a little guidance.
Fifty percent of students in the Oxford school district have free or reduced lunch. There is a program started by Oxford residents to help aid hungry children in the community, called Love Packs. The Love Packs program helps to ensure that students have extra groceries. The groceries are things that students can prepare themselves. Each week, I teach a lesson as part of my “Community of Helpers” program about how some students do not have enough groceries. I include at least one recipient, and we use a
wagon to deliver the snacks to the students. The student(s) who receive the Love Packs do not feel ashamed or embarrassed, and it works as a reminder for everyone to be thankful for what we have. Each month my school features a donation food of the month to help stock the Love Packs food pantry. I host a fundraiser at my school, honoring the classes who raise the most money with a pizza party and school-wide special recognition for their helping activities.
In addition, at our school there are students who need warm coats, shoes, and new clothing and underwear. I have a clothing closet that I rely on the community to stock. Students who live in poverty know that if they need clean or warm clothes, they can come and visit my closet.
I am currently working on a Christmas drive. I have 23 Love Pack recipients, and I am advocating and working with the community to keep the spirit of Christmas alive in the hearts of these youngsters by finding sponsors to help them have Christmas gifts, a tree, and Christmas dinner.
I am taking special field trips with all of the second graders at Oxford Elementary this year after completing service projects. We have already visited the Mississippi State Veterans Home; we sang patriotic songs and made cards to bring cheer and hope. I took another group to a nursing home for Christmas caroling and distributing Christmas cards. For Earth Day, we visited the local recycling center and participated in a clean-up at the lake. I also will complete a donation drive and a visit to our local animal shelter. One of my yearlong goals within the “Community of Helpers” theme is to participate in an opportunity of giving and extending random acts of kindness with all 300 second graders in my school. I encourage school counselors to get involved with their community and to relate to and understand the needs of their student population. Networking is crucial to advocacy and meeting the needs of the school population.
6. What has been your experience when interacting with national and local organizations, such as ACA and ASCA? Do you feel supported by professional organizations and leaders, and has this changed in the last 20 years?
Last summer, I had the pleasure of presenting at ASCA in New Orleans. This wonderful opportunity allowed me to connect with school counselors and counselor educators. My presentation focused on wellness and the importance of self-care when helping others.
I also had the opportunity to present for the past two years at the Law and Ethics in Counseling Conference in New Orleans. I reported on human services issues related to poverty and the lack of parenting education. This conference had valuable workshops regarding the legal and ethical guidelines of reporting child abuse that were extremely helpful to my work. There is a tremendous amount of social work involved in school counseling, and the Law and Ethics in Counseling Conference provided valuable educational guidelines to help deal with some of these issues.
When presenting, I am funded by the University of Mississippi to attend meetings because I am collaborating with my colleagues and professors in writing papers and conducting presentations. My school district also helps pay for my professional development. The Law and Ethics in Counseling Conference was amazing and offered insights related to professional development. The University of Mississippi has outstanding opportunities for growth regarding multiculturalism. I have taken my middle school students to the university’s religion festival on campus, and I was recently invited to the Saudi Arabian Festival by some of my parents.
7. Throughout your years of practice, what has been your experience when collaborating with other mental health and medical professionals?
Collaboration has been a key component in moving my school counseling program forward. When a student is in crisis, it is crucial to work with doctors to help the whole person. Also, in dealing with students who live in poverty, knowing and using community resources helps with the burdens that the student population faces. I take pleasure in helping parents with educational counseling, social work, alcohol and drug issues, and a variety of other problems that are not within my scope, which is why collaboration really saves lives. It is important to know the mental health agencies and what they offer within the community and to work as a team in order to provide the student population with all of the tools necessary to be healthy.
Collaborating with doctors has been the necessary piece of the puzzle that helps support students who are experiencing severe or unique problems. It is especially tricky to diagnose children; therefore, bridging the gap of communication between all the necessary players is a key component to providing the highest level of support and making the most informed decisions about how to help children.
A few years ago, I had a student who had an apparent medical issue but no presenting symptoms. The student went to a specialist for an examination. The doctor suggested that the symptoms might be psychosomatic and stress-induced; he had the family sign a release of information and get in touch with me. After meeting and collaborating with the doctor, we were able to successfully treat the phobia. Within a month, the physical symptoms subsided and the student began to heal emotionally. The student is now well adjusted and occasionally sends me a thank-you email. The student might not have improved without the collaboration among the doctor, teachers, and me. I have been very fortunate to have the opportunity to collaborate with members of my local health care professional teams to help the student population that I am serving.
8. For future school counselors, what advice would you have regarding their involvement in the advancement and future development of the profession?
My advice is to stay in school. Take at least one class per year if possible. Never stop learning. I learned more from taking random classes I was interested in than from working on my master’s degree. Also, attend professional workshops when possible and submit proposals to present at conferences. Presenting is a great way to grow professionally. I was fortunate enough to present twice at ASCA this year in Denver. Also, think of designing a guidance curriculum that fits the needs of your students. When I worked with middle school students, I had a club called “RAK” (Random Acts of Kindness) dedicated to helping others. The students involved needed to feel like a part of their school and to have a group in which to belong.
Also, pay attention to your own needs. I work hard to take care of myself. I am unable to help others effectively unless I am taking care of myself. I love the outdoors, exercising, trying to be healthy, and promoting wellness in my school.
This concludes the second interview for the annual Lifetime Achievement in Counseling Series. TPC is grateful to Joshua Smith, NCC, and Dr. Neal Gray for providing this interview. Joshua Smith is a doctoral student in counselor education and supervision at the University of North Carolina at Charlotte. Neal D. Gray is a professor and chair of the school of counseling at Lenoir-Rhyne University. Correspondence can be emailed to Joshua Smith at jsmit643@uncc.edu.
References
American School Counselor Association. (2012). The ASCA National Model: A framework for school counseling programs (3rd ed.). Alexandria, VA: Author.
Mississippi School Counselor Law, MS Code § 37-9-79 (2014).
Dec 3, 2017 | Volume 7 - Issue 4
Shengli Dong, Amanda Campbell, Stacy Vance
Professional identity development is crucial for counselors-in-training, as it provides a frame of reference for understanding their chosen field and contributes to a sense of belonging within the professional community. This qualitative study examined the impact of mindfulness on professional identity development among counselors-in-training. Participants reported that mindfulness, along with experiential learning and mentoring, served as a facilitator in completing the transformational tasks in the process of professional identity development. The preliminary results from this qualitative study warrant further research to examine and validate the impact of mindfulness on professional identity development among counselors-in-training.
Keywords: mindfulness, professional identity development, transformational tasks, counselors-in-training, experiential learning
The counseling profession has emphasized the importance of developing healthy professional identity among counselors-in-training (Corey, Corey, & Callanan, 2011; Council for Accreditation of Counseling & Related Educational Programs [CACREP], 2016; Granello & Young, 2011). Gibson, Dollarhide, and Moss (2010) defined professional identity development (PID) as the “successful integration of personal attributes and professional training in the context of a professional community” (pp. 23–24). A strong sense of professional identity provides an individual with a frame of reference for understanding his or her chosen field, contributes to a sense of belonging within the professional community, and helps to develop competency and an allegiance to the profession (Elman, Illfelder-Kaye, & Robiner, 2005; Pistole & Roberts, 2002). Conversely, a lack of professional identity may have negative consequences, such as detriments to the quality of counseling services (Pistole & Roberts, 2002) and role confusion among beginning practitioners (Studer, 2006).
Moss, Gibson, and Dollarhide (2014) and Gibson et al. (2010) proposed a transformational model in describing the development of professional identity across time among counselors-in-training and counselors. Specifically, the researchers reported that counselors passed through several transformational stages, including moving from idealism to realism, burnout to rejuvenation, external validation to internal validation, and separation to integration into the professional community, as they became more advanced. Additionally, counselors developed an internalized definition of counseling over time (Moss et al., 2014).
Developing professional identity can be a daunting task. On one hand, counselors-in-training and new professionals experience a variety of challenges in the course of PID. Some of these challenges include demanding academic and clinical work (Aponte et al., 2009), contradictory or ambiguous experiences triggering self-questioning and identity reshaping (Adams, Hean, Sturgis, & Clark, 2006; Slay & Smith, 2011), and a tendency to be self-critical and evaluate oneself primarily based upon external standards (Skovholt, Grier, & Hanson, 2001). In addition, counselor trainees tend to have an unrealistic view of their roles and capacity as a counselor (Thompson, Frick, & Trice-Black, 2011). These challenges may hinder the process of PID.
On the other hand, PID is a complicated process that involves transformational aspects such as cognition, behavior, and affection. A counselor-in-training or a new counselor develops a sense of oneness with a profession while addressing difficulty in balancing personal identity with professional identity (Goltz & Smith, 2014). Additionally, intense emotional interactions with clients and supervisors, such as constant exposure to professional evaluations, require consistent broadening and review of internal boundaries and perceptions (Birnbaum, 2008). Without successfully balancing these academic and professional requirements and expectations, counselors-in-training may encounter burnout. Thus, it is important for counselor educators and supervisors to assist trainees in the development of their professional identities (Auxier, Hughes, & Kline, 2003; Brott, 2006; Levitt & Jacques, 2005).
Most current approaches to PID focus on cognitive and behavioral aspects through experiential learning, continuing training, and supervision (Limberg et al., 2013; Zakaria, Warren, & Bakar, 2017). However, the aspect of affect also is of great significance. Several researchers have identified the significant impact of an affective component in the development of professional identity (Clouder, 2005; Mayes, Dollarhide, Marshall, & Rae, 2016). For example, Clouder (2005) stressed that affect development, which is highly associated with mindfulness (Schroevers & Brandsma, 2010; Snippe, Nyklíček, Schroevers, & Bos, 2015), should be integrated into PID.
Mindfulness and PID
Mindfulness is instrumental in affective development through emotional regulation (Hill & Updegraff, 2012; Hülsheger, Alberts, Feinholdt, & Lang, 2013). Mindfulness is a complex construct with several definitions. According to Kabat-Zinn (1994), mindfulness is conceptualized as “paying attention in a particular way: on purpose in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p.4). Similarly, Bishop et al. (2004) defined mindfulness as a two-component model, involving the “self-regulation of attention” and “a particular orientation towards one’s experiences in the present moment . . . that is characterized by curiosity, openness, and acceptance” (p. 232).
The benefits of mindfulness practices have been found in many areas, such as preventing and reducing burnout (Epstein, 2003; Rothaupt & Morgan, 2007), enhancing counseling competency (Campbell, Vance, & Dong, 2017; Greason & Cashwell, 2009), and fostering acceptance of one’s challenging thoughts and feelings as opposed to encouraging one to alter or control them (Davis & Hayes, 2011). In addition, Snippe et al. (2015) examined the temporal order of changes in mindfulness and affect and found that the changes in mindfulness seemed to predict and precede the changes in affect. The characteristics of mindfulness and its impacts on affect could potentially facilitate the transformational process in PID, which requires not only clinical and cognitive competence, but also affective and reflective capacities.
Although several studies have been conducted in the fields of social work, nursing, and psychology that have supported the relationship between mindfulness and PID (Birnbaum, 2008; Jacobowitz & Rogers, 2014; Martin, 2014), there is a lack of research exploring this relationship in the field of counseling (Beddoe & Murphy, 2004; Birnbaum, 2008; Louchakova, 2005). Furthermore, no study has focused on exploring a possible link between mindfulness and the transformational tasks in the process of PID. The purpose of this qualitative study was to explore how mindfulness may relate to the transformational tasks of PID (idealism to realism, burnout to rejuvenation, external validation to internal validation, and separation to integration) through the perspectives of mental health counselors-in-training.
Method
The qualitative approach for this study was informed by phenomenology and qualitative content analysis (Cho & Lee, 2014). Phenomenology was used as a framework to gain an understanding into participants’ experiences of PID through the potential impact of mindfulness among counselors-in-training. The qualitative content analysis offers a systematic method for identifying key themes among mindfulness and transformational tasks within the PID process among participants.
Participants
The participants in this study were master’s-level counseling students enrolled in two sections of an internship class during the last semester of their mental health counseling program (spring 2015) at a CACREP-accredited program of a Research I university in the southeastern United States. Six out of 16 students in the internship classes participated voluntarily in this study, with a participation rate of 37%. The sample included four Caucasian and two Hispanic participants, with four identified as female. The sample size of a qualitative study should be based upon goals and purpose of the study (Starks & Trinidad, 2007) and the depth of interviews—for more in-depth interviews, fewer participants are needed (Patton, 2015). Starks and Trinidad (2007) stated that the typical number of participants in a phenomenological study range from one to 10.
The participants conducted their internships in various settings, including an inpatient behavioral health center, a university counseling center, local community agencies, youth and family services, and low-income community services.
Procedures
The first author of this manuscript offered the internship course in which mindfulness-based practices and activities were discussed, demonstrated, and practiced. The mindfulness activities included meditation practices, readings regarding mindfulness, and weekly reflections on mindfulness practices for participants at their internship sites (mindfulness instructions and procedures can be obtained by contacting the first author).
The first author informed the students about the availability and voluntary nature of this study. The second and third authors (two doctoral-level students in the counseling program at the same university as the first author) came to the internship class and introduced the study, its purpose, nature and procedure, format, and the voluntary nature of participation. During that time, the course instructor (the first author) left the classroom. The students were informed that they would be invited to participate in this study via emails by the two doctoral-level investigators. Should students in the class agree to participate, the two doctoral-level investigators and the students would schedule a time to conduct interviews. All interviews were conducted by the second and third authors.
Prior to conducting the interviews, the doctoral-level investigators presented the interviewees with an informed consent form and told the interviewees that they could withdraw from the study at any time. Whether interviewees would participate or withdraw from the study would not be known to the course instructor and would not affect their grades for the class. In addition, data analysis was conducted after the end of the semester, when all the participants’ final grades had been submitted through the university’s grade submission system.
Each interview lasted about one hour and took place during the last four weeks of the spring semester of 2015. The interview included four open-ended questions, with two of these questions having additional probing questions. The semi-structured interviews served to better answer the research question. The interview began with questions regarding the participants’ professional development, including questions relating to internship site expectations, capability as an effective counselor, and the relationship between personal and professional identities. Next, the participants were asked questions pertaining to their experience in the internship class and internship sites, including questions about in-class mindfulness activities, internship site expectations, client interactions, and changes in professional identity. In addition, participants were asked about their self-care and mindfulness activities outside of the classroom. The interview concluded with a discussion about the factors that would aid participants to reach the next stage of their PID.
The interviews were audio-recorded and transcribed by the second and third authors. The transcripts were kept in a password-protected file and accessible only to researchers of this study. All identifying information was removed prior to data analysis. The audio recordings were deleted once all of the transcripts were cross-checked by the second and third authors to ensure the accuracy of the audio recordings and transcripts.
Qualitative Content Analyses
We used a qualitative content analysis approach to identify transformational tasks in PID and explore the potential impact of mindfulness on facilitation of completing transformational tasks. According to Cho and Lee (2014), qualitative content analysis is flexible in utilizing inductive or deductive analysis: codes or themes are directly identified from the data in inductive approach, whereas deductive approach starts with preconceived codes or categories derived from prior relevant theory.
We started the coding and data analysis process after all interviews had been completed, as suggested by Seidman (2013). In order to reduce or minimize the effect of our biases and preconceived assumptions on our interpretation of the meaning of the data, we engaged in bracketing (Moustakas, 1994) by reading the transcripts multiple times with the goal of embracing the participants’ perspectives while reducing the researchers’ preconceived notions on the topic (Hycner, 1999). Both the verbal and nonverbal (e.g., fillers and silences) content of the interviews were included in the transcripts.
The content analysis approach requires the researchers to review the data to ensure a thorough and integrative analysis. First, we carefully read each transcript and made notes identifying relevant information related to the research question. Second, we read the notes and listed the types of information found, then categorized interview content and notes in a meaningful manner. Third, we identified if connections between categories could be found or themes could be observed. Finally, we compared and contrasted various major and minor categories. The same process was repeated for each transcript. After analyzing all the transcripts, we identified themes and examined each in detail and considered if they were appropriate. Once all the transcripts were carefully examined and categorized into themes or subthemes, we reviewed the data to ensure that the information was categorized and described appropriately. Finally, we reviewed the transcripts and ensured that all relevant information was examined and categorized (Neuendorf, 2016).
Triangulation is the process through which a researcher gains confidence and assurance that their findings and interpretations of the data are reflecting what is actually occurring in the data (Stake, 2006), and it provides a check on selective perception and illuminates blind spots in an interpretive analysis (Patton, 1990). Content analysis with multiple researchers in this study offered opportunities for cross-checking and analyst triangulation. We each coded the interviews independently, and compared and contrasted categories and comments under each theme. When different opinions occurred, we discussed the discrepancies and brought light to data through multiple perspectives. The first author has research and clinical experiences related to mindfulness and PID, and past experiences in qualitative content analysis. The second and third authors have relevant research experiences in mindfulness and training in qualitative research.
Results
The results section describes the tasks in the transformational model of PID and their relationship to mindfulness based upon the participants’ responses. Under each transformational task, results are presented in two categories: (1) the transformational model of PID tasks, and (2) the impact of mindfulness on the transformational tasks.
Burnout to Rejuvenation
Transformational model of PID task. According to the results of the interviews, participants described being at different points on the burnout–rejuvenation continuum. Most commonly, participants noted multiple sources of burnout that accompanied their training experiences. These sources ranged from the nature of the work itself to an inability to cope with stress and multiple demands. For example, a male participant from a low-income community agency indicated nervousness at the prospect of being adjudicated as the result of a client complaining. In contrast, participants also cited their work as a means of rejuvenation. When given the opportunity to apply the knowledge that trainees had learned in class, participants often cited their practicum experiences as sources of excitement. One female participant from youth and family services and university services stated, “I’m excited and I want to get out there and see more and do more.”
Impact of mindfulness. A common theme emerged illustrating that participants viewed mindfulness as a strategy for reducing burnout and facilitating movement toward rejuvenation while developing their professional identities. Through building awareness of their internal and external experiences, participants noted a transition in the energy that they felt for their work. Specifically, participants noted initially feeling tired, stressed, and overwhelmed by their work. However, attending to these feelings, focusing on the here-and-now, and accepting the experiences nonjudgmentally helped participants manage feelings of burnout and ultimately feel an increased energy for their work. Participants perceived mindfulness as facilitating awareness of their internal and external experiences. One female participant working with an inpatient psychiatric hospital highlighted how mindfulness served as a facilitator for awareness of internal experiences: “I try really hard to focus on myself throughout the day using mindfulness, especially when I became overwhelmed where I could feel my body reacting, and that helped professionally because I could prepare for those situations.” In addition, a female participant from youth and family services noted that mindfulness served as a facilitator for awareness of external experiences, “[being] more mindful about where I was in the situation with a client so [I would not] get attached and bring that [vicarious trauma] home with me.”
Participants also noted mindfulness as facilitating acceptance of their internal experiences when faced with external stressors. For example, one female participant working at an inpatient psychiatric hospital and prison noted, “I mean deep breathing, especially when I’m feeling anxious . . . even when you’re just . . . feeling depressed, is nice to just [say] okay, ‘this is maybe just a phase I’m going through, it’s a normal reaction to everything that is happening.’” Furthermore, bringing awareness to all aspects of the internship through mindfulness activities helped relieve burnout and increase energy for work. For example, one participant working with an inpatient psychiatric hospital stated: “Really stopping and looking at the good times and the energy . . . in (the) workplace . . . and looking at the good things that happen really changed my view.”
Idealism to Realism
Transformational model of PID task. Participant responses revealed a pattern of adopting an idealistic perspective of the counseling process or outcomes, as well as unrealistic expectations of the counseling workplace. Responses demonstrated that some novice counselor trainees believed their roles were to “fix” or “save” their clients. For example, one participant at youth and family services noted, “a lot of the kids I have seen have been raped or sexually abused, neglected, abandoned. . . . I want to save every kid and I want to take every one of them home with me because I can feed them.” Other participants demonstrated having unrealistic expectations about the counseling workplace. Among responses collected, many participants defined counseling as “sitting there and listening to people” and noted beginning their internships with an idealistic perspective. For example, a female participant working with an inpatient psychiatric hospital stated, “Before, you have this idea of a counselor, sitting in a room with books around you and asking, ‘How do you feel about that?’” Many participants began with idealistic perspectives of their clinical skills and transitioned to more realistic expectations. For example, one female participant from a youth and family agency indicated that she had not anticipated the need to develop skills in helping, communicating, and connecting with parents prior to her internship, but had developed a more realistic expectation of her role in working with the parents of her clients.
Impact of mindfulness. Participants’ openness, awareness, and acceptance of experience are instrumental in the facilitation of realism in PID. Through an openness to experience in their internships, these novice counselors began to note a transition in their conception of the profession. Specifically, participants demonstrated attention to the here-and-now while engaging in their clinical experience, thereby allowing their understanding of the profession to be malleable to their therapeutic practice. One female participant from a youth and family agency noted that attending to the moment, rather than overpreparing, allowed her to remain open and flexible in her work with clients. Additionally, the participant stated mindfulness helped her with “being okay with not being okay . . . being more aware of my own feelings, accepting [clients] more, and dealing with [clients] in a better way than I normally would have.”
Furthermore, the participants were open to and accepted their experiences as opposed to rejecting their experiences because they did not fit with their pre-existing perception. Through the acceptance of their experiences, participants were able to begin to broaden their definition of counseling to a more realistic view. For example, a male participant from a low-income community agency noted, “we integrate counseling along with some aspects of basic-level social work case management; sometimes we are doing advocacy, sometimes we are doing a multitude of other things where counseling skills are helpful, but the counseling is not your direct . . . objective.”
Separation to Integration
Transformational model of PID task. With regard to separation to integration, participants at the beginning stages of training often viewed their professional identity as a separate entity from their personal identity. Many participants reported sustained effort in keeping their professional and personal identities separate when beginning their internship. For example, one participant reported “learning that it’s [her] identity as a counselor and not who [she is] as a person,” and further reported concerns about “bringing everything back home with [her] at the end of the day.”
In contrast, participants at the later stages of their training often perceived their professional and personal identity as one and the same. In this study, four of the six participants noted that their personal and professional identities are intertwined. For example, one male participant at a university counseling center stated, “I feel like I identify a lot with that [counselor] role. Sometimes it’s . . . hard to differentiate between taking off my counselor hat and keeping it on, even in some interpersonal . . . relationships.”
Impact of mindfulness. Responses from the participants also revealed that the integration process helped energize them. For example, one female participant at an inpatient psychiatric hospital stated, “Before, when I had jobs, I would separate myself. Because my career is so closely aligned with my personality, I feel like it’s the same. The way I am at my job energizes me; it makes me who I am.”
Additionally, some participants also indicated feeling comforted and integrated into the professional counseling community through accepting who they are and interacting with both peers and supervisors. For example, one female participant at youth and family services noted “knowing other resources to give clients and walking through the process of this is all that we can do with them . . . and then knowing that we did all that [we] could and that was okay.”
Similarly, there was one participant who noted that becoming integrated within the professional community helped with regard to becoming more internally validated. A female participant working in an inpatient psychiatric hospital noted that “things were finally starting to click into place where I was a part of the team . . . that was when my professional identity started to grow—when I see me as a professional instead of an intern.”
External to Internal Validation
Transformational model of PID task. Naturally, novice counselors experience doubt about their skills and capabilities in serving clients in a therapeutic capacity and often look to other more experienced professionals or resources for validation. Participant responses indicated that they were self-critical and looked toward others for validation of their experience. For example, one male participant from low-income community services indicated that when using professional manuals as an ultimate reference at the beginning of their training, “I didn’t trust myself to go off the manual . . . I was so concerned [about], okay did I cover this step, did I cover this step, did I cover this step.”
As the counselors-in-training developed their professional identity, there was a movement from external validation to being able to internally validate themselves. For example, the participant from low-income community services stated, “I am just now starting to trust myself to use the manuals as a base and then apply my own clinical judgment.”
Impact of mindfulness. One’s level of self-acceptance and tendency to not judge oneself is the key to the ability to validate oneself internally. Through nonjudgmentally accepting and evaluating oneself, participants were able to trust and internalize their own strengths and abilities. One male participant from a university counseling center stated, “I learned to accept the current level that I’m at, not being so critical on myself about what I should or shouldn’t be doing, or should and shouldn’t know . . . and that’s been helpful.”
Within this study, mindfulness appears to contribute to one’s willingness to expand the personal comfort zone and explore new and creative approaches, both of which facilitate development toward becoming an effective counselor. A male participant from the university counseling center stated, “It [mindfulness] helped me . . . step out of my comfort zone and try different things with clients, it’s been well received [and] really helpful in terms of feeling more competent [and] confident.”
Mindfulness assisted participants with accepting and trusting themselves, which develops internal confidence and validation. A male participant from low-income community services stated, “The basic concept of stopping yourself, examining in the moment, and saying okay . . . trusting myself that I could find the answer . . . if I allowed myself to relax, it made the client less agitated and less frustrated.”
Discussion
This qualitative study explored how mindfulness facilitates the transformational model of professional development (Gibson et al., 2010; Moss et al., 2014) in master’s-level counselor trainees. Although the extant literature within the field of social work has examined the role of mindfulness in PID (Birnbaum, 2008; Jacobowitz & Rogers, 2014; Martin, 2014), no research to date has examined this relationship within the counselor education field. This study employed a qualitative method, which offers contextual data on the experiences of counselor trainees’ PID. Thus, this exploratory study serves to address gaps in the literature by offering an understanding of how mindfulness may foster growth in counselor trainees’ PID.
The results of the study supported the transformational model of PID proposed by Gibson et al. (2010) and Moss et al. (2014). Indeed, participant responses supported each of the transformational tasks and seemed to hint that this process occurs as a continuum. Although participants were all master’s-level internship students at the completion of their program, each student demonstrated being in various places on the continuum on the four transformational tasks. For example, although some participants indicated a need to keep their professional identity and personal identity separated, others demonstrated beliefs that the professional and personal are intertwined, indicative of separated and integrated identities, respectively. Furthermore, participant responses alluded to change in their professional development over time, further validating the process of growth through the transformational tasks.
The emphasis of the current study was to examine how mindfulness may facilitate growth in PID through the aforementioned transformational tasks. Participant responses seemed to support that some participants found components of mindfulness assisted in their PID. The results showed that specific mindfulness facets associated with acceptance and a here-and-now orientation of internal experiences (e.g., thoughts, emotions, perception of self) and external experiences (e.g., internship experiences) contributed to more sophisticated PID perspectives.
The findings of this study support existing literature on mindfulness in counselor education. Wei, Tsai, Lannin, Du, and Tucker (2015) found that hindering self-focused attention, the antithesis of self-acceptance, led to diminished self-efficacy in counselor trainees. As this relates to the current study, many participants noted experiencing greater internal validation as a result of learning to accept their shortcomings as a counselor trainee. Similarly, participants indicated that self-acceptance yielded a greater propensity for rejuvenation. As suggested by Masicampo and Baumeister (2007), one’s acceptance of difficult thoughts and feelings allows for the development of affect tolerance. However, when counselor trainees are unable to accept their internal experiences (i.e., experiential avoidance), the negative emotional impact may be excessive and garner feelings of exhaustion and result in further manifestation of those avoided internal experiences (Hayes, Strosahl, & Wilson, 1999) or burnout. Indeed, the current research also suggests that self-acceptance played an important role in developing more realistic perspectives of their abilities and the profession. Corroborating evidence for this finding suggests that mindful acceptance and attention to the present moment allows counselor trainees to separate from the need to control themselves and their environment, thereby allowing themselves to be in the here-and-now with their clients and themselves (Christopher & Maris, 2010). In doing so, it is thought that individuals are able to see their abilities and profession as they are, thus developing a more realistic perspective.
In addition to mindfulness, participant responses also indicated a myriad of other experiences that contributed to their PID. Specifically, participants cited sources of growth such as experiential learning and field experiences, research, colleagues, supervisors, and coworkers. This finding is well supported in the literature on mental health counselors’ PID. Specifically, research on PID indicates that experiential learning; faculty, mentor, and supervisor relationships (Limberg et al., 2013); professional peer relationships (Murdock, Stipanovic, & Lucas, 2013); and professional organizations, such as the American Counseling Association (Reiner, Dobmeier, & Hernández, 2013), are all helpful in developing trainees’ professional identities, as they serve to validate shared experiences. Additionally, participant responses indicated that these sources of growth assisted many counselor trainees in becoming more integrated into the professional community.
An unexpected result was the various understandings and opinions regarding mindfulness expressed by participants. It was derived that some participants viewed mindfulness as a set of techniques and strategies (e.g., mindful breathing), whereas others considered mindfulness more as a state of being. For those adopting views related to the latter, responses indicated the acknowledgement of how awareness and acceptance of one’s internal and external experiences initiated progress in their PID. Although most participants adopted a positive view of mindfulness, perhaps because of their voluntary participation in a mindfulness study, a minority indicated that mindfulness was not personally beneficial to them, as they disliked using mindfulness techniques. Although there is a dearth of literature on the topic of those who do not benefit or dislike the use of mindfulness, La Roche and Lustig (2013) posited that the individual and the intervention that is being employed by the individual must match if it is to be effective. Indeed, it is possible that participants who did not find benefits from mindfulness maintain personal assumptions that are inherently distinct from, and perhaps incompatible with, basic tenets of mindfulness. In other words, the participants’ culture must be assessed and considered when attempting to employ mindfulness strategies in counselor trainees (Hyland, Lee, & Mills, 2015).
Limitations
Although this study provides a contextual understanding of how mindfulness may impact the PID of counselor trainees, it is not without limitations. The study implemented a convenience sampling procedure, recruiting counselor trainees from two sections of a course offered at one southeastern university. The final sample size was relatively small, including only six master’s-level trainees out of 16 students in the course, and was predominantly female (66%). The participants’ motivation to apply mindfulness practices and their knowledge of mindfulness could be different from that of their peers who did not attend the study. As such, the findings are limited to the sample used in the study and cannot be generalized to counselor trainees attending other universities or degree programs. Additionally, although the interviewers attempted to create a warm, nonjudgmental, welcoming environment, it is possible that participants may have felt hesitant to share their true experiences. Furthermore, all of the transformative tasks outlined in Moss et al.’s (2014) model were supported by the data; however, the use of a deductive approach may have led to confirmatory bias. Lastly, given the qualitative nature of this study, no causal inferences can be made with regards to the impact of mindfulness on PID.
Implications for Counselor Education and Further Research
The results of the current study indicate that mindfulness may contribute to the PID of counselor trainees through a variety of different mechanisms. As such, counselor educators may better assist counselor trainees in addressing barriers to PID through incorporating mindfulness-based approaches into curriculum and experiential activities. Counselor educators should work collaboratively with site supervisors to incorporate mindfulness into the supervision and field training experiences of counselor trainees, while also gathering feedback on the PID of counselor trainees over time. Furthermore, as some counselor trainees in this study demonstrated a superficial understanding of mindfulness (e.g., mindfulness as purely an intervention technique), students may benefit from the addition of a course focused on mindfulness and the PID process as a means to facilitate a deeper understanding of the philosophy and practice of mindfulness while fostering PID. Overall, counselor trainees may benefit from developing an understanding of the PID process and the benefits of mindfulness in facilitating both professional and personal growth.
Further research should incorporate larger sample sizes, varying degree programs, and multiple universities to develop a more general understanding of mindfulness and PID across counselor trainees. The impact of mindfulness on PID may be further examined using experimental and longitudinal research designs. For example, examining the impact of a mindfulness-based intervention on the PID of counselors-in-training, using pretest and posttest measures, and using a control group for comparison would add to our understanding of these phenomena. In addition, developing an understanding of mindfulness and PID may require moving beyond the self-report measure often used in social science to incorporating the feedback and observations of supervisors overseeing the work of counselor trainees within the clinical setting. Given the parallels between mindfulness and professional development (Beddoe & Murphy, 2004; Birnbaum, 2008; Louchakova, 2005) in other fields, as well as the findings of this study, deriving a mindfulness-based model of PID may prove beneficial for deepening the understanding of the connection between these two processes both in research and practical setting.
The complex and ever-evolving nature of PID is an area ripe for further exploration and discussion, particularly among counselor educators and trainees. The results of this exploratory qualitative study revealed that mindfulness facilitates engagement in the transformational tasks (i.e., burnout to rejuvenation, separation to integration, idealism to realism, and external validation to internal validation) in the process of PID for counselors-in-training. Considering the significance of PID and preliminary results in this study, further research is needed to examine and validate the impact of mindfulness on PID.
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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Shengli Dong, NCC, is an assistant professor at Florida State University. Amanda Campbell and Stacy Vance are doctoral students at Florida State University. Correspondence can be addressed to Shengli Dong, 114 Call Street, Tallahassee, FL 32313, sdong3@fsu.edu.
Dec 2, 2017 | Volume 7 - Issue 4
Chad M. Yates, Alexia DeLeon, Marisa C. Rapp
Counselors-in-training may struggle in working with addictions populations for various reasons, including limited training, pre-existing stigma toward the population, and low self-efficacy treating substance use disorders. This is concerning because professional counselors have the highest proportion of clients with a primary substance abuse diagnosis. The authors explored the experiential learning approach of an abstinence project within an addictions course in an attempt to give students a genuine experience that parallels what an individual with an addiction may experience. The authors utilized generic qualitative analysis to explore the experience of 17 counseling students completing the abstinence assignment. The emergent themes of (1) concrete experiences, (2) dealing with cravings, (3) student’s self-reflection of learning, and (4) empathetic understanding and challenging attitudes are presented. Finally, future areas of research and implications for counselor educators are discussed.
Keywords: substance use disorders, abstinence assignment, generic qualitative analysis, counselors-in-training, addictions
Counselor educators face considerable challenges in providing comprehensive and effective training for counselors-in-training (CITs) serving persons with substance use disorders (SUDs). These challenges include students’ unfamiliarity with addictions or addicted populations, few opportunities to infuse addictions-related materials into the general curriculum, and no uniform national curriculum standards for addictions-related education (Chasek, Jorgensen, & Maxson, 2012; Salyers, Ritchie, Cochrane, & Roseman, 2006). This is concerning, as addiction remains a consistent issue for the general population. Approximately 21.5 million Americans meet criteria for an SUD (Substance Abuse and Mental Health Services Administration, 2015), reinforcing the need for competent addictions counselors. Professional counselors (excluding specified addictions counselors) have the highest proportion of clients with a primary substance abuse diagnosis, in comparison to social workers, psychologists, and psychiatrists (Harwood, Kowalski, & Ameen, 2004). Additionally, CITs also treat clients with addictions much more frequently during their training. Salyers et al. (2006) found that a high percentage of CITs see clients in their practicum and internship experiences who present with substance abuse concerns. Due to the frequency of addiction concerns counselors and CITs treat, it is imperative that counselor education programs continue to address training necessary to accommodate these concerns.
In response to the growing need to train effective addictions counselors, the Council for Accreditation of Counseling & Related Educational Programs (CACREP; 2016) constructed standards that counselor educators should infuse within the curriculum. The integration of the standards across all CACREP-accredited programs has been slow, but a 2013 survey of programs found that 76.7% of counseling graduates had at least one course related exclusively to substance abuse counseling (Iarussi, Perjessy, & Reed, 2013). This is a substantial increase considering Salyers et al.’s (2006) findings that only 58.2% of counseling graduates had taken at least one course related to substance abuse counseling. Starting in 2009 and continuing within the 2016 standards, CACREP specifically called for counselors to understand the theories and etiology of addictions and addictive behaviors, including strategies for prevention, intervention, and treatment (CACREP, 2016). These changes have provided steps toward greater competency in the treatment of addictions; however, most students still have only one course during their program devoted to addictions (Chasek et al., 2012). As most counseling education programs continue to only have a single course devoted to addictions education, it is critical to investigate the educational experiences of CITs and explore the educational experiences that maximize student learning.
A common concern when educating CITs about addictions is the attitudes and biases they bring with them to an addictions course (Chasek et al., 2012). The pre-existing attitudes and behaviors espoused by CITs are often derived from moralistic notions of addiction (Chasek et al., 2012). Clinicians’ negative attitudes toward persons with addictions often lead to reduced outcomes in treatment (McLellan, Lewis, O’Brien, & Kleber, 2000). Blagen (2007) suggested that negative attitudes need to be addressed during training to help CITs facilitate relationship building with persons with addictions. A common tool utilized in addictions training to foster empathy and understanding of persons with addictions is the abstinence assignment. The abstinence assignment asks students to abstain from a substance or behavior for a set period and journal about the experience. This learning approach has been explored in a pharmaceutical education program (Baldwin, 2008), allowing students to successfully meet all four of the course’s learning objectives: (1) describe feelings and experiences related to the process of withdrawal from habituating or addicting substances or activities; (2) describe the importance of abstinence in the maintenance of recovery from habituating or addicting substances or activities and discuss the implications of relapse to the recovery process; (3) discuss the importance of support systems in recovery from habituating or addicting substances; and (4) describe the process of addiction and recovery (Baldwin, 2008).
Baldwin (2008) found generally favorable opinions of the assignment and strong ties to reflective learning through class surveys conducted before and after the assignment. However, no study to date has explored students’ learning processes during an abstinence assignment. The aim of the current study was to understand the pedagogy behind the abstinence assignment and to explore the experience of students completing the project. It was hoped that the study would reveal if the abstinence assignment could foster empathetic experiences for persons with addiction and if the assignment could enhance understanding of withdrawal, craving, and relapse. Specific research questions included: (a) what, if any, were the empathetic experiences of students concerning clients with addictions; (b) how was the concept of craving experienced and made meaningful by participants; (c) what were the elements of the learning process for participants completing the abstinence assignment; and (d) how did students find ways to deal effectively with cravings and abstinence through the project? This study utilized qualitative data analysis methodology to explore the experiences of 17 CITs who completed an abstinence assignment during their addictions course. A review of pertinent literature follows.
CITs often face considerable difficulty learning addiction-specific tools and skills. These challenges typically arise due to students’ limited exposure to persons who are addicted, limited experiences of cravings and triggers, limited understanding of the lives of those with addictions, and limited self-efficacy of being effective with this population (Harwood et al., 2004). This lack of awareness, coupled with classroom material that is disconnected from the students’ experiences, may lead students to feel unprepared for treating clients with addiction concerns. The infusion of experiential learning activities is one way to counter the above concern. Kolb (1984) stated that learning new concepts involves directly encountering these concepts within real world experiences. In Kolb’s theory, “Learning is the process whereby knowledge is created through the transformation of experience” (Kolb, 1984, p. 38). Effective learning is seen when a person progresses through a cycle of four stages: (1) having a concrete experience, followed by (2) observation of and reflection on that experience, which leads to (3) the formation of abstract concepts (analysis) and generalizations (conclusions), which are then (4) used to test hypotheses in future situations, resulting in new experiences (Kolb, 1984). Experiential learning is a means of acquiring knowledge through action and feelings; it creates an emotional understanding and challenges attitudes (Warren, Hof, McGriff, & Morris, 2012).
Sias and Goodwin (2007) explored an experiential learning approach of CITs attending 12-step meetings and then journaling their experience. Students attending 12-step meetings reported growth and new awareness of the experience of persons with addictions. Students described the fear and uncertainty clients faced when beginning a support group. They also reported challenging their pre-existing stereotypes of persons with addictions, through interacting with those in recovery. Results from studies such as Sias and Goodwin (2007) can help further understanding of the barriers in learning about addictions and also help educators implement experiential learning approaches more intentionally.
Barriers to Learning
In training emerging clinicians to work with persons with addictions, research has revealed that many trainees lack empathy and emotional understanding for this population (Baldwin, 2008; Giordano, Stare, & Clarke, 2015; Sias & Goodwin, 2007). Research has shown the struggles CITs may experience in showing empathy, emotional understanding, and challenging bias toward persons with addictions. These struggles may impact the quality of care toward persons with addictions (Chasek et al., 2012; Giordano et al., 2015). Furthermore, many CITs report poor self-efficacy in being clinically effective with persons struggling with addictions (Harwood et al., 2004). Celluci and Vik (2001) found that approximately 144 mental health providers in Idaho who treated persons with an SUD rated their graduate training as inadequate preparation for treating clients with an SUD. The importance of strong educational experiences is reinforced by Carroll (2000). Carroll reported that CITs with more addictions courses were increasingly likely to treat or refer a client for an SUD and to think of an SUD as a distinct disorder, compared to CITs with less addictions training.
Another potential learning barrier for students is negative stigma toward persons with addictions. Society’s negative portrayal of those battling addictions may play a role in counselor trainees’ perceptions and attitudes regarding this population (McLellan et al., 2000). For instance, the general public is reported as viewing persons with drug addictions negatively, as blameworthy and dangerous (Corrigan, Kuwabara, & O’Shaughnessy, 2009). CITs possess similar negative attitudes, beliefs, and biases regarding addictions and addiction treatment (Chasek et al., 2012). These authors investigated CITs’ attitudes toward persons with addictions and the effectiveness of substance abuse counseling. They concluded that students who had less bias toward persons with addictions were more likely to view treatment for substance abuse as effective.
Counselor educators are charged with the responsibility to ensure that competent counseling professionals are entering the field (CACREP, 2016). As present research shows the struggles that many CITs are facing in relation to persons with addictions, it is vital that further research is conducted to examine how counselor educators can remedy this known lack of empathy and emotional understanding through pedagogical intervention. Although anecdotal evidence from past generations of counselor educators has shown the experiential assignment of abstaining from a substance as useful, to date no counseling literature exists that shows empirical evidence for this assumption. Consequently, we investigated the experience of students utilizing the abstinence assignment and built upon the limited understanding of integrating an abstinence assignment into addictions curriculum.
Qualitative Research Design
Generic qualitative analysis (GQS; Percy, Kostere, & Kostere, 2015) was employed as a qualitative methodology to examine the pedagogical implications of utilizing an abstinence assignment within an addictions course. GQS seeks to understand and discover the perspectives and worldviews of participants and is intended to explore what participants directly experienced, or what the experience was about (Percy et al., 2015). The present study utilized existing abstinence journals and reflection summaries that included descriptions and reflections of students’ experiences of participating in the abstinence assignment; it was deemed appropriate to use a qualitative methodology that would support the analysis of these data resources (Percy et al., 2015).
Participants
The participants selected for the study were master’s-level counseling students enrolled in their second and last year of study. These students were enrolled in an addictions counseling course, and a major course requirement was an abstinence assignment. Students were instructed to select a substance or behavior from which they wished to abstain for 4 weeks. There was a total of 17 participants (14 females and three males). The ages of participants ranged from 24 to 44 years with a mean age of 26. All 17 participants identified as White. Participation in the study was solicited after the participants completed their abstinence journals and reflective summaries, and received grades for the assignment. The participants were informed that participation in the study was completely voluntary and would have no impact on their grade. Data analysis was conducted once the course was completed. Of the 17 participants, the following is a list of the chosen substances or behaviors with the number of students: Soda or Carbonated Beverages (3), Sugar (4), Alcohol (3), Eating Out at Restaurants (2), Social Media or Entertainment Activities (3), Procrastination (1), and Evening Snacking (1).
Abstinence Assignment
This exercise was designed to help students experience some of the feelings/thoughts that addicted individuals experience when they quit their drug or behavior of choice. Students were told: This exercise requires that you give up a substance (e.g., nicotine, caffeine, or alcohol) or a behavior (e.g., eating sweets, playing video and computer games, watching television) for a period of 4 weeks. During this assignment, you will write a goodbye letter to your substance or behavior detailing why you are choosing to give up the substance or behavior and what the substance or behavior means to you, and you will keep an abstinence log of your experiences. This log will describe your feelings and reactions, especially focusing on times you “lapse” or experience cravings (minimum one page log of two entries per week). Finally, you will write a summary paper, which will serve as the conclusion to the 4-week exercise.
Data Analysis and Trustworthiness Procedures
The researchers obtained Institutional Review Board approval prior to the analysis of the data. Data analysis procedures were followed according to the guidelines set forth by Percy et al. (2015). The researchers first familiarized themselves with the study materials—which included a goodbye letter to the substance or behavior, abstinence journals, and reflection summaries—by reading through each item and making notations (highlights) about significant statements that reflected the research questions for the study. The above step was performed independently by the first and second author for all 17 transcripts. The two researchers (authors one and two) met at two different times, once halfway through the initial transcript analysis and again at the end to compare and contrast notes.
After this step was completed, the researchers compared notes to identify common theme listings from the data. The researchers created a definitional agreement for each emergent theme. The goal of this step was to isolate significant themes represented in both researchers’ notes. Each researcher had to agree that there was ample evidence to support this theme and agree on the mutual definition of this theme. To aid the researchers in coding, the work of Kolb’s Experiential Learning Model (Kolb, 1984) was incorporated into the coding procedures to link existing learning theory steps to the process that was being discovered within the transcripts. Once the coding structure was in place, the first author coded each of the 17 participant transcripts. Coding each participant was performed by highlighting significant statements that represented the theme and its definition. For example, the researcher coded a significant statement from Participant 1: I can see why this is so difficult for some people to stay sober; I’m having a hard time and only . . . giving up sugar. This significant statement was coded as empathy. Upon completion of this coding, both researchers independently reviewed the list of significant statements under each theme and noted if the statement was representative of the existing theme definition. If the significant statement was not representative, it was either discarded or represented under a more appropriate theme.
The researchers met upon completion of this step to share the results of the review of significant statements. The researchers then decided if each change to the significant statement was warranted. Following the above step, the researchers organized all themes into similar categories. After this categorization was complete, the researchers utilized an auditor outside of the study who shared a similar background and training in qualitative research to review the significant statements under each theme and identify if they were representational to the existing theme definition and if the themes fit within their designated category. The auditor made notes about significant statements to discard or to move to another theme. Upon completion of the auditor’s review, the category, theme structure, and theme definitions were emailed to each participant of the study for member checking. Each participant was asked to comment on the list of themes and the researchers’ definitions of each theme to ensure that they were credible. Participants with comments for the researchers were contacted again, and category and theme structures were reviewed and revised based on the participants’ input.
Results
Four themes emerged during the data collection process. The first theme was “concrete experiences” of the participants completing the abstinence assignment. This theme contained several subthemes, such as withdrawal cues, cravings, relapse, justifications of relapse, shame after relapse, and triggers. The second theme that emerged was “dealing with cravings.” Within this theme were the subthemes of replacement behaviors and relapse avoidance. The third theme contained elements of “student’s self-reflection of learning.” This theme contained two subthemes: reflective observation and abstract conceptualization. The last theme consisted of statements showcasing students engaging in empathetic understanding and challenging their attitudes or perceptions of persons with addictions.
Theme One: Concrete Experiences
Theme One contained participant descriptions of completing the abstinence assignment. These concrete experiences, cravings, relapse, and shame over relapse are similar to experiences of persons beginning and sustaining recovery. The most often identified statement from participants was craving for their identified substance. Participant 3 journaled, “Sometimes I wish I could just take all of my cravings and put them in a jar and smash the jar so I don’t have to deal with them anymore.” Beginning to deny the use of a substance had begun to produce strong desires often unknown by participants. Participant 15, who abstained from soda, described hearing a soda dispenser and the physical effect she noticed in her body for the first time, “It was odd to note that I had a sensation go through my entire body as I heard it. It made me think and consider Pavlov’s dogs. Truthfully, I thought about Diet Coke the rest of the day.” Cravings were often accompanied by withdrawal in participants who had given up substances they had consumed over long periods. Participant 12 reported, “Today I was run-down and fatigued, and I developed a low-grade headache that stayed with me all day. And even though I ate more than I usually eat in a day, I felt like I was starving.”
Reading through the 17 participants’ journals, researchers found consistent patterns of subthemes often occurring in a sequential order. The subthemes order was descriptive of a trigger or cravings, followed by relapse, justification for the relapse, and finally shame and guilt over the relapse. Upon review of the participants’ transcripts, this pattern was found in 15 of the 17 participants and occurred between one and three times per participant. Participant 13, who abstained from sugar, described a cycle of trigger, craving, relapse, justification of relapse, and shame over relapsing: “Tonight was Superbowl Sunday. My aunt made a gluten free cake with dulce de leche and strawberries on top, and I ate two slices . . . I felt like I deserved it because I was doing so good on this abstinence assignment.” Participant 13 further recalled, “I feel a little bad about it now, but I honestly feel like it was justifiable and I plan on going back to the no sugar and no gluten thing again tomorrow anyway.”
Instances of complete breakdown on the students’ abstinence goals often appeared. These especially occurred with students who chose substances like grains, carbs, or sugar. The defining elements of these complete breakdowns were a sense of low self-efficacy and overwhelming guilt and shame. Participant 10, who abstained from fast food, expressed, “I have eaten at fast food restaurants three times since last Thursday . . . I literally feel disgusted at myself that I haven’t been able to control my cravings or at least have enough self-control to just be mindful about my choices.” The experience of emotional and physical symptoms related to abstaining from a behavior or substance prompted students to begin exploring effective personal strategies for dealing with their cravings.
Theme Two: Dealing With Cravings
Paralleling the experience of individuals in the early stages of recovery, participants actively dealt with cravings in various ways, including healthy and unhealthy coping mechanisms. When participants selected strategies that were unhealthy or unhelpful, the researchers labeled these as replacement behaviors. These behaviors often consisted of replacing their substances with other substances. For example, switching from sugary foods to fatty or salty foods, and avoiding a trigger or cravings by staying overly busy. These behaviors are not new to professionals working with clients with addictions. Below are examples of the participants engaging in these replacement behaviors. Participant 1, who abstained from soda, described noticing her behaviors as, “I ate a lot more . . . than I normally do. Because of how many chips I was eating I realized that I had replaced my drink [soda] with chips and salsa.” Noticing the pattern was a valuable learning experience that helped the participant to confront her substitution later in the assignment.
However, other students were unable to observe the ties connected to these behaviors and future relapse. Participant 5, who abstained from social media, reported, “I was also very busy the last couple of days because I’ve been preparing for my counseling presentation. Maybe I’ve successfully distracted myself from the temptation.” Nearly all participants reported engaging in replacement behaviors at some point in their experience. However, many of these participants discovered more successful ways to cope with triggers and cravings. When participants reported positive craving coping strategies, the researchers labeled these experiences as relapse avoidance strategies. These strategies often involved the elimination of potential triggering events or objects within the participants’ environments, relying on significant others and family members for support, talking to classmates about their cravings, and using healthy substitutions in place of their substance.
Participant 5 reported an instance of a relapse avoidance strategy: “I actually uninstalled and deactivated my Twitter. That way if I go to tweet something, I would have to download the app and activate my account. Two layers of activity would definitely put a damper on impulsivity.” Additionally, Participant 6, who had given up sugar, reported, “I got rid of all the sugar in the house.”
Relying on classmates and family was often described as essential from participants who reported they felt they had successfully abstained. Participant 3, who abstained from sugar, reported, “I talked with one of my friends about how the relapse has impacted my overall motivation and she really helped me get through and process.” Participant 5 added, “I’ve enlisted the help of my husband—(he) agreed to check my Twitter handle to make sure it is deactivated. This keeps me honest. I like the accountability piece because I can’t tweet in secret.” The healthy substitution often resembles behaviors like a step-down program or funneling energy into healthy activities and hobbies such as exercising or spending time with close friends. Participant 3, described replacing sugary sodas with a healthier alternative: “I found this type of soda . . . that is basically naturally flavored water. To say it’s curbed my sugar craving is an understatement.” Others described tending to general wellness to alleviate the stress associated with abstinence. Participant 7, who abstained from alcohol, reported, “I noticed myself going to sleep earlier yesterday . . . which I believe was a coping strategy for dealing with my irritability of trying to relax without allowing myself to have a drink.”
These strategies represent active experimentation and learning about how best to be successful at abstaining from the identified substance or behavior. Reflections on these experiences were essential to the learning goals associated with this project. The next theme explores these reflections and provides insight into the learning that was taking place throughout the assignment.
Theme Three: Student’s Self-Reflection of Learning
Theme Three explored the elements of personal learning the participants reflected upon. The researchers identified learning through Kolb’s Experiential Learning Model (Kolb, 1984). The researchers were interested in participants’ statements that evidenced reflective observations, defined as observations and reflections on what their experience was about and how it resonated with them. The researchers also were interested in participants’ statements that evidenced abstract conceptualization. We defined abstract conceptualization as the reflection upon concepts related to treating persons with addictions followed by generalizations from these reflections to future work with clients.
Examples of reflective observation can be found within Participant 2’s description of her difficulty in remaining abstinent from television for the assignment and how she discovered the difficulty of the change process within herself: “I feel like all I’ve done is replace not thinking because I watch mindless shows on television to not thinking because I play mindless games on my phone. I’ve thought about replacing it with exercise, but I feel myself rebelling against that.”
Many of the participants’ reflections facilitated greater awareness about how difficult it was to change any reinforced behavior or the difficulty of abstaining from a substance or behavior. Many reflected on discovering the difficulty of living without their substance or behavior. Participant 4, who abstained from social media, described, “It was very surprising to me when I realized how automatic my impulses were and how often I gave into them. During this time, my eyes were opened to how much this habit impacted my life.” In addition to discovering how hard it was to live without something they once enjoyed, many participants described experiencing new insight into the minds and behaviors of persons in recovery. Participant 13, who abstained from sugar, described, “It was much more difficult to abstain when I was around people who were consuming around me. I felt a greater social pressure and found myself feeling insecure (and) disconnected in social settings.” Participant 13 reported that pressure to continue was difficult to maintain: “Once I relapsed and we were nearing the end of the four weeks, it was hard for me to remain motivated to continue . . . the craving, the desire to connect with people and fit in, and the unexplainable high I get from eating sugar and gluten had to be outweighed by something else.”
Additionally, participants described the change process as something tangible and less theoretical. Participants could describe and reflect upon where they were within the stages of change and began to appreciate the difficulty of sustaining lasting change. Participant 11, who abstained from alcohol, described her awareness of the change process as, “Change doesn’t just happen overnight; it requires many things, including commitment, energy, the right motivation, and the right timing.” In addition, Participant 3, who abstained from sugar, added, “I talk in my notes at my site all the time about motivation for change and what that looks like for each of my clients, and I couldn’t even apply it to myself.”
The participants began to understand the experience of what counselors were asking clients to do by abstaining from drugs or alcohol. They also began to understand how to apply this learning to clients who were currently struggling with addictions and help with the understanding of the concepts of addiction. Participant 12, who abstained from sugar, reported, “This experience helped me understand how counterproductive it is to tell other people what they need to do to change. People don’t change until they are ready . . . to assume that a person will change just because someone tells them to is a mistake.”
Additionally, participants recalled what was most difficult about abstaining and built stronger conceptualizations about the role of triggers in relapse. Participant 17, who abstained from alcohol, reported, “I went dancing with some friends last night at a bar in town and found myself being asked several times why I wasn’t drinking.” This participant expressed the frustration about the experience as, “It began to get really annoying, and I feel (it) gave me some insight into the role that others play in the process of addiction and becoming sober, and how risky it can be in certain environments.”
The application of the experience of abstinence impacted all of the participants to some degree. Overall, they stated they felt a greater capacity of empathy for persons with addictions based upon how difficult abstinence was. Most participants reflected that the way they viewed a person in recovery was altered based on their experience of abstinence. The assignment generated new learning opportunities and understanding of the concepts of addiction and also enhanced their empathy for clients suffering from addictions. This enhancement of empathy was found within Theme Four, discussed below.
Theme Four: Empathy and Attitudes
The participants all stated that a significant learning outcome of the assignment was empathy for those with addictions. Participant 3, who abstained from sugar, reported, “I can see how people would struggle giving up drugs when their body has such a dependence on their drug of choice. I am struggling and counting down the days and I’m only giving up sugar.” This empathy was often associated with a strong protest that they were only experiencing a small proportion of the suffering that persons in recovery go through. Participant 10, who abstained from fast food, described growing his awareness of persons with addictions as, “I know one of my limitations in counseling is not being able to relate to my clients because I haven’t experienced some of the things that they have, like an addiction.” Participant 10 discussed the benefits from the abstinence assignment as, “by doing something as simple as this, I feel that I am in a much better place to help clients.”
Other participants described that empathy helped them deepen their understanding and care for those in their close family who had gone through addictions. Participant 17 reported, “I have personally observed my father going through his journey in alcohol and opiate addictions. I have felt the pain, suffering, frustration, and struggle as a family member, which makes this assignment very personal for me.” Participants reported these empathetic gains as important because they provided new perspectives on the lives of persons with addictions. Gaining empathy helped move participants closer to understanding persons with addictions as human beings who were attempting to steer themselves away from alcohol and drugs. This helped them to combat previous biased views of persons with addictions and altered previous attitudes and beliefs that are ineffective in helping this population.
Discussion
This study explored the pedagogy behind an abstinence assignment and the experiences of students who participated. Specifically, the researchers wished to discover (1) What, if any, were the empathetic experiences of students concerning clients with addictions; (2) how was the concept of craving experienced and made meaningful by participants; (3) how did students find ways to deal effectively with cravings and abstinence through the project; and (4) what were the elements of the learning process for participants completing the abstinence assignment? A discussion of the research questions, including analysis of the themes, follows.
Empathetic Experiences of Students
Addressing bias and negative stigma associated with persons with addictions is a major aim of most addictions courses, as negative stigma has contributed to lower therapeutic outcomes for clients struggling with addictions (McLellan et al., 2000). This study explored the empathetic understanding of students completing the abstinence assignment and found that participants reported accessing empathy for persons struggling with addictions through experiences of craving, triggers, and relapse. Moreover, students empathized with the pain and suffering that abstaining produced and described the needed patience of treating clients with addictions. This empathy was fostered through an experiential understanding of craving, which is better explored within the second research question of how students found ways to effectively deal with cravings and abstinence via the project.
Experiences of Craving
An essential element of Kolb’s Experiential Learning Model (Kolb, 1984) is concrete experience. A concrete experience is a learning stage that involves having students experience a phenomenon physically, mentally, and psychologically. Although the experiences from the abstinence assignment are only approximations of individuals with addictions, they may still be important, as they provide students insight into withdrawal, craving, triggers, relapse, shame, and justification concerning relapse. This study’s first theme supports the learning objective that students experienced genuine addiction-related experiences. Students were cognizant that their experiences may not have perfectly compared to individuals addicted to drugs and alcohol; however, they stated often that the abstinence assignment produced suffering and uncertainty over their ability to abstain successfully from their chosen substances or behaviors. Students also reflected upon how they learned to cope through effective and ineffective ways with the experiences of craving and relapse. This was encouraging, as it provided students with strategies on how to help future clients during recovery.
Effectively Dealing With Cravings
Students often struggle with understanding where to start treatment with persons entering recovery (Carroll, 2000). This uncertainty may stem from unfamiliarity with the experiences of addictions and from lack of awareness of appropriate therapeutic goals for clients suffering from addictions. Students in this study reported understanding the concepts of triggers and cravings much more tangibly, while often discussing how they would broach these topics more readily with clients after completing the abstinence assignment. The students also reported ways they found to effectively manage their cravings that they felt could be useful to explore with clients in the future. These ways included many of the well-established treatment interventions for addictions that advocate for removal of all substances or substance use–related materials from home; restructuring daily living to replace or avoid triggering things, places, or times; the building of a supportive structure of family and peers; allowing others to hold the person responsible for future substance use; limiting exposure to cross-dependency through the use of other substances; actively discussing current cravings and triggers with family or peer support; and relying on healthy living strategies, like eating and sleeping well, to bolster defenses against triggers. We see from the list above that students were able to extrapolate strategies through abstaining from a substance or behavior to their work with clients. A closer inspection of Theme Three, students’ self-reflection of learning, found further support for the application of this project.
Elements of the Learning Process
In examining the students’ learning process, this study was interested in discovering if Kolb’s model could be an effective explanation of students’ learning during the abstinence assignment. It was discovered that the stage of concrete experiences was experienced during the period of abstaining. The assignment also required a reflection log or journal and a summarization paper. Within these portions of the assignment, the researchers found ample evidence to support that students engaged in reflective observations that helped them assign meaning to their experiences during abstaining, and also provided room for students to actively think through what these experiences meant for their work with clients (i.e., abstract conceptualization). Due to time considerations and inaccessibility to students, the researchers were unable to observe elements of Kolb’s fourth stage (i.e., active experimentation). Future research might build upon the present design to investigate the application of skills with CITs having undergone an abstinence assignment.
Implications for Counselor Education
Madson, Bethea, Daniel, and Necaise (2008) explored current training within counseling psychology and mental health counseling programs and recommended key areas educators should attend to within the realm of addictions. These areas included: (a) thoroughly assess SUD, (b) determine the appropriate level of treatment, and (c) develop treatment plans that include evidence-based substance abuse treatment (Madson et al., 2008). Madson et al. identified key areas that closely aligned with CACREP Standard II.3.D., which calls for counselors to understand the theories and etiology of addictions and addictive behaviors, including strategies for prevention, intervention, and treatment. It is the authors’ belief that the abstinence assignment helps students prepare for the above standards in a way that surpasses traditional didactic content. Speculatively, this may be why the abstinence assignment has been seen as a hallmark of addictions training. Baldwin’s (2008) investigation of abstinence assignments found that 69% of participants felt the abstinence assignment had a major positive effect, and 44% of participants agreed that they better understood the process of addictions recovery as a result of the assignment. This study aimed to build upon Baldwin’s findings; specifically, to explore if the abstinence assignment was found valuable by students; and to discover if it provided a valuable learning experience about the phenomenological experiences of persons with addictions, an understanding of the symptoms of addictions, and an understanding of preliminary treatment approaches to use with clients. The researchers found key themes within the research that supported the assignment meeting the above learning goals. With these findings, the authors believe in the continued infusion of this assignment within counselor education.
The abstinence assignment carries pedagogical considerations for an educator to take into account before including it in the curriculum. These considerations include how an instructor intends to provide feedback and assess the reflection journals. Content of feedback should be considered to help elicit further reflection for the student to deepen the learning experience. Moreover, the instructor will want to consider ethical issues that may arise from the grading of this assignment. If a student is disclosing dangerous or high-risk behaviors or demonstrating signs or behaviors of a process addiction, instructors will need to address their concerns and support the student’s developmental needs.
Future Research
There are several recommendations for future research. First, future research is needed to examine the application of skills with counselors who have completed an abstinence assignment. Qualitative and quantitative inquiry could provide insight as to whether students are translating their learning from this assignment into clinical practice. Secondly, research may expand upon this study by examining students’ prior experience with addictions or persons struggling with addictions to inquire if prior knowledge influenced their learning experience. Finally, continued empirical exploration into additional pedagogical interventions to examine effectiveness in addictions curriculum is needed.
Limitations
Several limitations exist within the current study. A primary limitation known from the beginning of the study was the utilization of a class assignment as the primary means of data collection with all White participants. While other studies have utilized class assignments as means of data collection (Baldwin, 2008; Sias & Goodwin, 2007), it is unknown if participants provided consistently accurate representations of their progress, or if different types of students would have different experiences. This limitation was partially mitigated by encouraging journaling and reflection upon success and failures during abstinence. Another limitation was the inability to monitor the application of the learning material potentially being applied with internship clients.
Conclusion
Researchers investigated the pedagogical advantages of utilizing an abstinence project within an addictions course, along with exploring the empathetic understanding of students completing the abstinence project. Elements of their learning process were identified and results found that students reported increased empathy for persons struggling with addictions through their experience of abstinence. The authors recommend employing the abstinence assignment in an addictions course curriculum in counselor education. Future research is needed to examine the application of skills with counselors having undergone an abstinence assignment.
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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Chad M. Yates is an assistant professor at Idaho State University. Alexia DeLeon is an assistant professor at Lewis & Clark. Marisa C. Rapp is a doctoral student at Idaho State University. Correspondence can be addressed to Chad Yates, 921 South 8th Ave, Stop 8120, Pocatello, ID 83209-8120, yatechad@isu.edu.
Dec 1, 2017 | Volume 7 - Issue 4
Hannah E. Acquaye
Refugees report several mental health challenges associated with pre-, peri-, and post-flight conditions. Some of these challenges include fear, anxiety, hypervigilance, hyperarousal, and nightmares—symptoms that could meet the diagnostic criteria for post-traumatic stress disorder (PTSD). Despite these challenges, some refugees also report psychological growth with nomenclature like post-traumatic growth, resilience, and benefit-finding. This study examined the directional relationship among war-related events, optimism, PTSD, religious commitment, and growth. Prior studies in traumatized samples have demonstrated that PTSD and growth can occur concurrently, while optimism and religiousness may enhance growth. The hypotheses undergirding this study posited that participants in this non-Western population could demonstrate concurrent PTSD and growth, while those with higher levels of optimism and religiousness would exhibit increased levels of growth compared to those with lower levels. For a sample of 444 former refugees, hypotheses were theoretically modeled to identify whether the data fit the model. Inspection of fit indices provided support for the hypothesized model. Implications for professional counselors are included and recommendations for future research are provided.
Keywords: refugees, post-traumatic growth, PTSD, optimism, religious commitment
Professional counselors who work with refugees, specifically refugees resettled as a result of war or conflict, hear their clients share the harrowing experiences encountered on their journeys toward safety (Clay, 2017; International Counseling and Community Services [ICCS], 2015). War-related internally displaced persons (IDPs) and refugees, more than immigrants or other displaced people, report suffering inhumane acts like ethnic cleansing (United Nations, 2017). Others describe running through forests to avoid warring tribal factions, defending themselves against wild animals and forces of nature, and going without food for days (Betancourt et al., 2015). These experiences can be traced through the precipitating events leading to their flight, the flight progression, and finally the pathways to resettlement. Each of these processes incurs a traumatic adjustment. Clients among this population have reported diverse somatic symptoms and physical challenges (Cline, 2013; Edge, Newbold, & McKeary, 2014), as well as difficulties associated with basic physiological needs (e.g., food, water, shelter; ICCS, 2015; Maslow, 1970). They have described symptoms that meet the criteria for diagnosing post-traumatic stress disorder (PTSD; American Psychiatric Association [APA], 2013; Zerach, Solomon, Cohen, & Ein-Dor, 2013), depression (APA, 2013; Praetorius, Mitschke, Avila, Kelly, & Henderson, 2016), anxiety (APA, 2013; ICCS, 2015; Praetorius et al., 2016), and bereavement (APA, 2013; ICCS, 2015).
Dated research has examined these conditions in refugees through the lens of psychopathology; however, studies spanning the past three decades have emphasized the salutogenic components of post-trauma experience (Antonovsky, 1987). Salutogenesis originates from the Latin salus, meaning “health,” and was developed by Antonovsky (1987), who suggested that when people encounter stress, not all will have negative health outcomes. He therefore entreated researchers to use a strength-based lens instead of a deficit-based one in understanding human reactions to stress (Antonovsky, 1993). Although a strength-based perspective of post-trauma paths was not a new concept (Splevins, Cohen, Bowley, & Joseph, 2010), it had not yet been systematically and scientifically catalogued in the academic literature until the early 1990s. Since then, there has been a plethora of studies addressing people’s strengths and resources despite hardships (Affleck & Tennen, 1996; Bonanno, 2004; Joseph & Linley, 2005; Tedeschi & Calhoun, 1996). Proponents of strength-based post-trauma paths have applied their unique nomenclature to signify the strength and benefit that clients report obtaining despite their encounters with diverse traumatic events. Terminologies such as post-traumatic growth (PTG; Tedeschi & Calhoun, 1996), benefit-finding (Affleck & Tennen, 1996), stress-related growth (Park, Cohen, & Murch, 1996), thriving (O’Leary & Ickoviks, 1995), resilience (Bonanno, 2004; Connor & Davidson, 2003), and adversarial growth (Joseph & Linley, 2005) have been associated with this concept of meaningful positive change from a traumatic experience. The common theme among these writers is that there can be positivity and strength in places in which we expect weakness, illness, and pathology. Subsequent sections of this paper will address various outcomes known to follow a traumatic experience, connect them to theories associated with these experiences, and extract hypotheses to be tested.
Aftermath of Traumatic Experiences
When humans encounter traumatic experiences, they try to make meaning of them by using available resources. While some of these resources can be physical, others are psychological and emotional. Psychological and emotional resources could include inner narratives, religious communities, spirituality, connections with significant others, and nature. Optimism and religious commitment could also be included in the psychological and emotional resources that clients use to make meaning of their war-related traumatic experiences.
Trauma and psychopathology. Trauma is described as challenging experiences that push individuals beyond their normal ability to cope (APA, 2013; Ball & Stein, 2012). Trauma is ubiquitous, with research reporting that 60–80% of adults do experience at least one traumatic event (Simiola, Neilson, Thompson, & Cook, 2015). Traumatic experiences include robbery; terminal illness, for both the sufferer and loved ones; flooding; earthquakes; terrorist attacks; rape; and war-related events, for both civilians and the military. While many people who go through traumatic experiences may not have long-term negative repercussions, between 10–50% report various mental health challenges (Friedman, Resick, & Keane, 2014).
Studies on traumatic experiences in adults have collectively established that after a traumatic encounter, people report and exhibit various symptomatology of PTSD, including avoidance, intrusive thoughts, negative alterations in cognition and mood, and the tendency to live recklessly (APA, 2013). Individuals who experience the direct effects of these traumatic events are not the only ones affected. Research has identified long-lasting effects on significant others (Lahav, Kanat-Maymon, & Solomon, 2016; Zerach, 2015) and helpers (Baum, 2014) because of the regular contact with traumatized individuals. Terms like secondary traumatization, vicarious traumatization, and compassion fatigue (Jenkins & Baird, 2002) have been used to describe the reaction to emotional demands from trauma survivors’ frightening and shocking images. Accordingly, significant others and helpers may sometimes react as if they themselves have gone through the traumatic events.
Based on the literature on war-related military and civilian populations, it is hypothesized that at least 10% of participants in the present study would meet the criteria for PTSD, with a cut-off point of 33 on the PTSD assessment instrument (Weathers et al., 2013).
Trauma and psychological growth. Another aftermath of a traumatic event is PTG (Tedeschi & Calhoun, 1996). The processes of rumination, meaning-making, and growth take place after the perceived shaking of a traumatized person’s worldview (Calhoun & Tedeschi, 2014), and eventually the person is able to put the event into perspective and gain a level of growth from the experience. In the words of the proponents, “PTG involves internal changes that can set the stage for changed behavior. There is variation in the degree to which personal changes can be noticed by others in terms of actions taken” (Tedeschi, Calhoun, & Cann, 2007, p. 399).
As a construct, PTG is seen as a legacy of trauma, containing “at least three broad categories of perceived benefits” identified by individuals and sometimes by the people in their lives (Tedeschi & Calhoun, 1996, p. 456). The three categories include changes in (a) self-perception, (b) interpersonal relationships, and (c) philosophy of life. PTG occurs when a person endures a traumatic event of seismic proportions that destroys some pivotal part of the person’s worldview (Tedeschi & Calhoun, 2004). Theoretically, PTG has been conceptualized as both an outcome and a process (Zoellner & Maercker, 2006). PTG as an outcome represents substantial positive changes in cognitive and emotional life that could be the opposite of PTSD. The constructs are not two ends of the same continuum; PTG does not imply either an increase in well-being or decrease in distress. Although PTG and PTSD are distinct and independent constructs, prior studies suggest that both phenomena can coexist in traumatized individuals (Powell, Rosner, Butollo, Tedeschi, & Calhoun, 2003). These constructs have both been observed to be higher in females than males, even when trauma experiences are greater in males (Ball & Stein, 2012; Friedman et al., 2014).
Based on these findings, it is hypothesized that both male and female participants can exhibit cohabiting symptoms of distress and growth, with females exhibiting higher PTSD and PTG scores. For the sake of this study, PTG is defined as the collective expression of growth and benefit that clients claim to gain after the type of cataclysmic event that challenges their existing worldviews (Calhoun & Tedeschi, 2014; Tedeschi & Calhoun, 1996, 2004).
Optimism. The concept of optimism is grounded in theory and research (Carver, Scheier, & Segerstrom, 2010) that explores what motivates people and how motivation is expressed behaviorally. Optimism is the belief, hope, and confidence that good things will happen in a person’s life instead of bad things (Carver & Scheier, 2002; Rand & Cheavens, 2012). Carver, Scheier, Miller, and Fulford (2009) stated that optimists are not disillusioned, but rather they acknowledge the existence and importance of adversity and choose to identify both internal and external resources that can help them cope.
Relationships between optimism and trauma have been examined in diverse groups of individuals who have encountered adversity. Research has demonstrated that individuals who perceive they are able to cope have a positive outlook on life and expect good things to happen because they can control their environments (Benight & Bandura, 2004). There also is evidence that a person’s disposition to optimism may be attributable to certain environmental factors (Broekhof et al., 2015). In the Broekhof et al. (2015) study, optimism was found to be inversely related with all subtypes of childhood trauma; however, important sociodemographic, clinical, and lifestyle characteristics moderated this inverse relation. Moreover, literature relates optimism to positive mood and good morale (Peterson & Steen, 2012). Positive mood and good morale lead to perseverance and effective problem solving (Fredrickson, 2001), which in turn lead to overcoming negative traumatic symptoms. People who are generally optimistic often explain causes of events that happen to them and use these explanations as a stepping stone toward growth from adversity (Peterson & Steen, 2012).
Additionally, optimistic or hopeful people are able to make informed decisions on their health based on provided information (Rand & Cheavens, 2012; Scheier & Carver, 1985). In a study on health and hope, high-hope women could perform better on a cancer facts test than their low-hope counterparts, even when controlling for previous academic performance. Not surprisingly, hope was inversely related to intentional attempts at self-harm because self-harm efforts are incompatible with the physical health goals that hopeful and optimistic people strive to achieve. Although there are a few scattered studies on Asian populations, there are limited studies within non-Western populations on how optimism and pessimism relate to quality of life (Chang, Sanna, & Yang, 2003); thus, the present study will contribute to the literature by testing the construct of optimism across cultures.
Consequently, it is hypothesized that participants who report higher optimism, despite their shared traumatic experiences with those who report lower optimism, will report higher PTG scores.
Religious commitment. Religiousness, religiosity, and religious commitment are constructs that are often confused and sometimes used interchangeably with spirituality (Brownell, 2015; Pargament & Mahoney, 2012; Pargament & Maton, 2000). Spirituality is a continuous search for the sacred (Batson, Schoenrade, & Ventis, 1993). Religion can also be expressed as human practices and behaviors concerned with a search for the sacred—a search founded on dogma, traditional practices, and institutional regulations (McIntosh, Poulin, Silver, & Holman, 2011; Pargament & Maton, 2000). Spirituality is an individual experience and does not necessarily work in an institutional setup like religion does.
Even though past research has not distinguished between religiosity and spirituality (Pargament & Mahoney, 2012), current researchers are consistently contrasting the two, with some asserting that religion is dogmatic, restrictive, and institutional, whereas spirituality is subjective, personal, and life-enhancing (Brownell, 2015; King & Crowther, 2004; Pargament & Mahoney, 2012; Prati & Pietrantoni, 2009). In many studies, participants often identify themselves as both religious and spiritual, which is not surprising because both religiosity and spirituality can be expressed individually as well as socially, and both can either hinder or foster well-being (Pargament & Mahoney, 2012).
In the discourse on PTG, religious coping is identified as a strong predictor of growth and partially shares the same descriptions as spirituality (McIntosh et al., 2011; Prati & Pietrantoni, 2009). However, Joseph (2011) cautioned against the assumption that higher PTG indicates higher religiosity. His caution has received corroboration from a qualitative study in Australia (Barrington & Shakespeare-Finch, 2013), in which participants in a grounded theory study described a decrease in religious commitment as indicative of psychological growth. The researchers surmised that participants whose trauma was related to their religious faith probably needed a shift in worldview about religion. Such a shift sometimes required lowered religious commitment to ensure psychological growth. This Australian study is in line with Joseph’s (2011) observation that growth could mean a decrease in religious commitment for one person and an increase for another.
In another research study, a sample of 54 students who had experienced major traumatic events took part in a study that examined the association between event-related rumination, pursuit of religion and religious involvement, and PTG (Calhoun, Cann, Tedeschi, & McMillan, 2000). Despite the study’s inability to determine longitudinal direction of effect, results provided evidence that openness to religious change independently predicted the amount of reported growth in the participants. In yet another study on the role of spirituality and religiosity in the physical and mental health after collective trauma, religiosity and spirituality were found to be highly correlated (McIntosh, et al., 2011). Religiosity, like spirituality, predicted higher levels of positive affect. Interestingly, religiosity, but not spirituality, predicted lower incidence of mental ailments.
Overall, with respect to physical health, religiosity was associated with decreased incidence of musculoskeletal ailments three years after the traumatic experience. Psychologically, religiosity was correlated with lower incidence of mental ailments, positive affect, and fewer cognitive intrusions three years after the 9/11 attacks. In sum, religious commitment has been found to enhance psychological growth after a traumatic experience. It is therefore hypothesized that participants in this study who endorse greater levels of religious commitment will have higher PTG scores.
There are contradictory results concerning the relationship between PTSD symptoms and PTG in traumatized populations. While some studies reported a positive relationship between PTG and PTSD (Hussain & Bhushan, 2011), others reported a negative relationship (Kimhi, Eshel, Zysberg, & Hantman, 2010). Proponents of the positive relationship suggested that higher distress symptoms lead to high growth. Contrarily, those who reported the negative relationship reported that distress predicts growth. Other studies have found no relationship between distress and PTG (Widows, Jacobsen, Booth-Jones, & Fields, 2005). Yet, others have identified a curvilinear relationship (Kleim & Ehlers, 2009; Kunst, 2010), in which results have indicated that higher scores of PTG are related to mild PTSD symptoms and vice versa.
Post-traumatic distress and growth need not be mutually exclusive. Results of several studies have indicated that it is possible for both PTSD symptoms and positively perceived effects of the trauma experience to coexist, even in war-related traumatized populations (Powell et al., 2003). In these studies, participants may have experienced the trauma to a greater degree; however, they reported that using their internal resources, like optimism and spirituality, contributed to their positive perception of the experience. Based on the literature reviewed, this study is situated on the following hypotheses:
Between 10–50% of participants will meet the diagnostic criteria for PTSD. Furthermore, both males and females will exhibit co-occurring PTSD and PTG, with females showing higher scores in both PTSD and PTG than males.
Those who report high optimism, despite the war-related experiences, will have higher PTG scores than those with low optimism.
Those with high optimism will also score high on religious commitment.
Those with high religious commitment will score higher on PTG.
In sum, the objective of this paper was to identify post-traumatic trajectories within a sample of former war-related IDPs in a developing country. In the process of assessing the trajectories, the study will also establish reliability of Western-based instruments in a non-Western population.
Method
Participants
Participants for the study were adults from the West African country of Liberia who, because of the decade-long civil conflict, became IDPs or refugees. The only West African country not colonized by any of the European colonial masters (i.e., Britain, France, and Portugal), Liberia became a known republic in the 1820s. This occurred when freed slaves were brought from the Americas to the coast of Liberia. The indigenous people inhabiting the land prior to the arrival of the freed slaves were dissatisfied with how the latter, referred to as Americo-Liberians, governed the land (Gerdes, 2013; Verdier et al., 2008). This dissatisfaction festered until its culmination in an over decade-long civil conflict (1989–2003). It is estimated that more than 10% of the population died in the civil conflict (Verdier et al., 2008).
This study used a multi-stage sampling method (Fraenkel, Wallen, & Hyun, 2015). In the initial stage, criterion sampling was used for adult Liberians who were known to be former refugees and IDPs. The number of participants gained after the first sampling stage was less than the expected 500 participants. Snowball sampling was therefore employed to reach the target sample size. Because Liberia has no database of residents, participants had to be contacted face-to-face at community meetings, colleges, churches, and mosques.
Procedures
All procedures of the university’s institutional review board were followed; informed consent
was provided in both verbal and written form and undertaken via individual and group formats. Additionally, local healers and pastors were introduced to participants in anticipation of traumatic memories culled up from the questions on some of the instruments. The incorporation of local healers and pastors was consistent with research in similar areas and cultural practices (Van Dyk & Nefale, 2005).
Procedural criteria for inclusion were determined prior to data collection. Participants had to be 18 years of age or older, able to read and understand English at the eighth-grade level, and old enough during the war to have remembered the flight. Participants were thereafter given the informed consent and research package, which had been printed and numbered. Participants who preferred to complete the instruments in group format stayed after class or a church service for this activity. Others chose to take it home and bring it back to the researcher at an agreed-upon place. Announcements were made to participants to provide contacts they could recommend who fit the procedural criteria.
When all of the 500 packages had been distributed, data collection stopped. Of packets given, 444 were completed and returned, demonstrating an 88.8% response rate. Statistical power was estimated at .80 for this model using the SAS syntax provided by MacCallum, Browne, and Sugawara (1996). Based on this syntax, a sample size of 200 (df = 179) was considered adequate. Our sample size of 444 was therefore acceptable for an effect size of .80.
Instruments
Six instruments were given to participants. They were the Post-Traumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996), the War Trauma Screening Index (WTSI; Layne, Stuvland, Saltzman, Djapo, & Pynoos, 1999), the Revised Life Orientation Test (LOT-R; Scheier, Carver, & Bridges, 1994), the Religious Commitment Inventory (RCI-10; Worthington et al., 2003), the Post-Traumatic Stress Checklist for DSM-5 (PCL-5; Weathers et al., 2013), and a demographic questionnaire.
PTGI. The PTGI is a 21-item scale that measures positive changes that occur in people’s lives because of crises. The scale comprises five subscales (factors). The subscales and sample questions are: (a) relating to others (e.g., I more clearly see that I can count on people in times of trouble); (b) new possibilities (e.g., I developed new interests); (c) personal strength (e.g., I know better that I can handle difficulties); (d) spiritual change (e.g., I have a stronger religious faith); and (e) appreciation of life (e.g., I can better appreciate each day). Each item is rated on a 6-point Likert-type scale ranging from 0 (I did not experience this change as a result of my crisis) to 5 (I experienced this change to a very great degree as a result of my crisis). The range of possible scores a participant can obtain is from 0 to 105. The PTGI has demonstrated high internal consistency (α = .90; test-retest reliability = .71) and acceptable construct validity (Calhoun et al., 2000). The instrument is not correlated with measures of social desirability (Baker, Kelly, Calhoun, Cann, & Tedeschi, 2008). PTGI scores for the Liberian sample demonstrated high internal consistency (α = .93), providing support for the cross-cultural nature of the instrument in consistently measuring the construct of PTG.
WTSI. The WTSI is a 35-item dichotomously scored self-report instrument. The instrument was used to measure participants’ experiences during the Liberian war, and it was chosen because of its simplicity in assessing what participants saw, touched, or had done to them. Sample questions include, “During the war, did a bullet ever come so close to you that you could have been seriously hurt or killed?” and, “During the war, did you eyewitness someone being killed?” The highest score a person can obtain is 35. There is currently no reported psychometric evaluation of this instrument. On a cursory look, the instrument seems to be divided into broad categories consisting of (a) attack to self; (b) attack to loved one; (c) forced displacement; and (d) witnessing trauma. These four factors were therefore used as part of the structural equation modeling (SEM) procedure. Reliability analysis of the 35 items for the Liberian sample demonstrated high internal consistency (α = .90).
LOT-R. The LOT-R is a 10-item scale that evaluates dispositional optimism. The instrument has four fillers (items 2, 5, 6, and 8), thereby leaving only six items to be used for analysis. Three items are reverse coded (items 3, 7, and 9) before undertaking any analysis. Each item is rated on a 5-point Likert-type scale, ranging from 0 (strongly disagree) to 4 (strongly agree). Sample items include “In uncertain times, I usually expect the best” and “If something can go wrong for me, it will.” The LOT-R has acceptable internal consistency (α = .78), test-retest reliability (α = .60–.79), and discriminant (r =.48–.50) and convergent (r = .95) validity (Scheier et al., 1994). Reliability of the 6-item scale in the Liberian sample was modest (α = .49).
RCI-10. The RCI-10 measures the degree to which a person stands up for his or her religious values. The 10-item scale is measured on a 5-point Likert-type scale, ranging from 1 (not at all true of me) to 5 (totally true of me). The RCI-10 has two factors—intrapersonal and interpersonal religious commitment. The intrapersonal religious commitment assesses an equivalent of personal commitment not related to the social component of religious faith. Interpersonal, on the other hand, measures the social component associated with organized religious faith. Sample items include “Religious beliefs influence all my dealings in life” and “I spend time trying to grow in understanding of my faith.” A cut-off score of 38 and above is needed to identify a highly religious person. Evidence indicates that people who score more than one standard deviation above the mean view the world in terms of their religious worldview (Worthington et al., 2003). Evidence of reliability for the norm groups was high, and both construct and criterion-related validity were similarly high (Worthington et al., 2003). Internal consistency for the Liberian sample in this study was acceptable (α = .84).
PCL-5. The PCL-5 measures distress symptoms after a traumatic experience. The 20-item instrument is ranked on a 5-point Likert-type scale ranging from 0 (not at all) to 4 (extremely). The scale comprises four subscales, consistent with the DSM-5 PTSD Clusters B, C, D, and E. The subscales and sample questions are: Cluster B, or Intrusion (e.g., repeated, disturbing, and unwanted memories of the experience); Cluster C, or Avoidance (e.g., avoid memories, thoughts, or feelings related to the experience); Cluster D, or Negative Alterations in Cognition and Mood (e.g., having strong negative feelings such as fear, horror, anger, guilt, or shame); and Cluster E, or Alterations in Arousal and Reactivity (e.g., taking too many risks or doing things that could cause you harm). Psychometric properties for the instrument demonstrated high internal consistency (α = .91), two-week test-retest reliability (α = .95), and convergent validity (r = .87; Wortmann et al., 2016). Results of reliability analysis for the Liberian sample demonstrated a high internal consistency (α = .92).
Data Analysis
Data were analyzed with three programs. SPSS (version 24; IBM, 2016) was used for descriptive statistics to understand participants’ demographics. SPSS was used to assess reliability of instruments and to answer the first research question. Finally, SPSS was used to extract the correlation matrix that was the foundation of both the confirmatory factor analysis (CFA) and SEM. SAS (SAS Institute, 2015) and AMOS (version 23; Arbuckle, 2014) were used for both the CFA and SEM.
The Hypothesized Model
Figure 1 represents the hypothesized model based on hypotheses extracted from the literature. It is hypothesized that all participants experienced the 10-year civil war. It is hypothesized that between 10–50% of participants will meet the diagnostic criteria for PTSD. It is also hypothesized that PTSD and PTG can co-occur in participants. It is further hypothesized that those who report higher optimism scores will have higher PTG scores. Finally, it is hypothesized that those who report higher religious commitment scores will have higher PTG scores.
Figure 1. The Hypothesized Model
With SEM, there are two basic variables—unobserved and observed (Schreiber, 2008). Unobserved variables are called latent factors and are graphically depicted with circles or ovals. Observed variables are called manifest variables and are represented graphically with squares or rectangles. Large circles in the graphic represent latent constructs, and small circles represent measurement errors (in observed variables) or disturbances (in equation measurement). Straight, single-headed arrows are indicative of unidirectional paths. The arrow starts from the independent variable and points to the dependent variable. A curved arrow connecting two variables indicates two variables expected to co-vary; however, no hypothesis is made about their causality (O’Rourke & Hatcher, 2013).
Finally, SEM comprises two components: a measurement model, also called CFA, and a theoretical or structural model (Schreiber, 2008). While the measurement model specifies the relationship of the latent to the observed variables, the structural model identifies specific relationships among the latent variables. The objectives of the SEM are to determine whether a theoretical model is supported by the data collected, and to test the hypothesized direct relationships between independent, or exogenous, variables and dependent, or endogenous, variables. The hypotheses testing in SEM consists of several analyses of variances and regressions occurring simultaneously. Through this, researchers also can test mediated relationships between variables and examine the reliability of items to latent variables in a single test.
Several fit indices are reported in SEM as a global examination of how well the collected data fit the hypothesized model (Hu & Bentler, 1998; Schreiber, 2008; Sivo, Fan, Witta, & Willse, 2006). Because of well-known problems of fit estimation using chi square (χ2) in large data sets, the Bentler’s Comparative Fit Index (CFI) was used with values at .95 or higher, indicating a good-fitting model (Hu & Bentler, 1998; O’Rourke & Hatcher, 2013; Sivo et al., 2006). An absolute index, the Standardized Root Mean Square Residual (SRMR), and a parsimony index, the Root Mean Square Error of Approximation (RMSEA), were used as indices assessing the difference between the proposed model and actual variances and covariances in the data. RMSEA values less than or equal to .06 and SRMR values less than or equal to .08 are preferred (Fabrigar, Porter, & Norris, 2010; O’Rourke & Hatcher, 2013; Sivo et al., 2006).
Results
Demography of Participants
Participants’ ages ranged between 28 and 65 years. Many fell within the 31–40 year range (45.7%). More participants were male (70.9%) than female, and many were unemployed (63.7%). Of those who were employed, 34.0% earned less than US$720 a year. Family demographics were varied: 42.3% of participants were single, 30.0% were married, and 23.6% lived with their partners. Many participants (49.3%) had one or two children.
The majority of participants (89.2%) indicated they were displaced during the Liberian civil war. There was no follow-up question to identify how some participants could have stayed in their homes despite the reported rampage that affected the whole country (Verdier et al., 2008), so I can only speculate that they either did not read that question well or had a way to stay safe during the war. Of those who were displaced, 60.4% became internally displaced, while the rest became refugees in and out of Africa. Almost half (48.4%) of the former refugees and IDPs had returned to Liberia since the cessation of the war. Additionally, to assess participants’ reaction to the Ebola epidemic and its possible ability to trigger traumatic experiences (Doucleff, 2015), participants were asked to compare the effect of the epidemic to the effect of the civil war on their mental health. The majority (65.8%) indicated that they linked the epidemic to the war several times a day, a process that could re-traumatize those who may have undisclosed PTSD symptoms.
Results From Hypotheses
The first hypothesis proposed that between 10–50% of participants in the study will meet the diagnostic criteria for PTSD (as measured by PCL-5), as well as co-occurring symptoms of distress and growth based on gender. Results of the descriptive statistics indicated that the majority (351; 79.1%) met the criteria for PTSD. Additionally, results from the one-way multivariate analysis of variance indicated that there was a statistically significant difference in post-trauma pathways based on gender (F[2, 376] = 6.016, p = .005; Wilk’s λ = .972, partial η2 = .028). Gender had a statistically significant effect on PTG (F[1, 377] = 6.354, p = .012, partial η2 = .017), but not on PTSD (F[1, 377] = 3.039, p = .082, partial η2 = .008). The PTG mean score for females (X̅= 84.49, sd = 16.030, n = 109) was higher than for males (X̅= 79.56, sd = 17.663, n = 270). Both males and females demonstrated co-occurring PTG and PTSD. Even though there was a statistically significant difference in PTG scores based on gender, there was no such difference in PTSD scores.
Hypotheses two through four were analyzed with SAS and AMOS to test the confirmatory model and the theoretical model, and to provide graphical representation. Missing data analysis was computed through the relationship between missing values on each variable of the 444 responses. Data were missing completely at random, and no statistically significant relationships were observed among variables. Listwise deletion within the correlation matrix reduced the sample size to 350.
The present analyses followed Anderson and Gerbing’s (1988) two-step procedure. The first step used CFA to develop a measurement model meant to establish an acceptable fit to the data collected. The second step was a theoretical model that was a modification of the measurement model. This modified model is a structural equation model representing the theoretical model of interest. The theoretical model was then tested and revised until a theoretically meaningful and statistically acceptable model was achieved.
The measurement model. A measurement model describes the nature of the relationship between several latent variables and the manifest indicator variables that measure those latent variables. The measurement model investigated in this study consisted of five latent variables corresponding to the five constructs of the post-trauma pathways model: War, PTSD, Optimism, Religious Commitment, and PTG (N = 350). Each of the five latent variables was measured by at least two manifest variables (Figure 2).
Figure 2. The Confirmatory Factor Analysis (CFA) Model
The maximum likelihood estimation successfully converged in 40 iterations. The correlations table was consulted for multicollinearity; only one relationship was above .90. The relationship between war-related threat to self and intrapersonal religious commitment was .93. The fit indices indicated an acceptable fit of the data to the hypothesized structure. The CFI was .94, SRMR was 0.056, and RMSEA was .050, with a 90% confidence interval of .042–.058. All items loaded statistically significantly (p < .05) on the theorized latent variables and no modifications were warranted based on the values calculated (see Table 1). The squared multiple correlations, an indicator of reliability of items, seemed acceptable, except for some items loading onto the optimism factor. These results were unsurprising considering the low Cronbach’s alpha of the instrument in this sample.
The theoretical model. The 5-factor solution hypothesizing the directional relationship successfully converged in 29 iterations. Using the maximum likelihood estimation, evidence from the model suggested that the data did not fit the model as expected (CFI = .932, SRMR = 0.062, RMSEA = 0.052). Although all parameters within the model indicated statistically significant t-values, one of the paths linking two latent constructs was non-significant. The standardized path coefficient from religious commitment (F3) to growth (F5) was not significant (t = 1.87, se = 0.25, p = 0.06). Further, inspection of the squared multiple correlations table indicated that R-square values relating to the negatively worded optimism items (3, 7, and 9) were weak (< .25).
Revised model. To look for the best fitting model, the Wald test and the Lagrange multiplier tables were consulted. The Wald test provides information on parameters that can be dropped to improve the model. The Lagrange multipliers provide information on parameters to be added. Experts caution researchers to ensure that data-driven model modifications do not capitalize on chance characteristics of the sample data, as they have the tendency to produce a final model that is not generalizable to the population or to other samples (O’Rourke & Hatcher, 2013; Schreiber, 2008). Researchers are therefore encouraged to identify parameters that could be dropped from the model without significantly affecting the model’s fit, as it is generally safer to drop parameters than to add new parameters when modifying models (O’Rourke & Hatcher, 2013). The Wald test suggested the intrapersonal variable within the religious commitment factor be dropped. Even though that suggestion was deemed statistically feasible, it was not theoretically feasible. Furthermore, because of the problems associated with the negatively worded items in the optimism scale, the errors associated with those items were allowed to covary.
When the three errors were covaried, the model was reanalyzed. The maximum likelihood successfully converged in 19 iterations. The revised model fit the data well (CFI = .953; SRMR = 0.049; RMSEA = 0.044). All path coefficients were nontrivial and statistically significant (i.e., t > |1.96|). Figure 3 depicts standardized path coefficients for the revised model.
Table 1
Regression Weights and Squared Multiple Correlations (SMC) of the Measurement Model
|
Standardized |
|
t-value (standard error) |
|
|
War |
PTSD |
LOT |
RC |
Growth |
|
War |
PTSD |
LOT |
RC |
Growth |
SMC |
| Self |
0.37 |
|
|
|
|
|
7.51 (0.05) |
|
|
|
|
0.14 |
| Witness |
0.64 |
|
|
|
|
|
17.22 (0.37) |
|
|
|
|
0.41 |
| Displac |
0.68 |
|
|
|
|
|
19.48 (0.04) |
|
|
|
|
0.47 |
| Loved1 |
0.94 |
|
|
|
|
|
34.37 (0.03) |
|
|
|
|
0.88 |
| Avoid |
|
0.49 |
|
|
|
|
|
11.00 (0.04) |
|
|
|
0.24 |
| Intrude |
|
0.53 |
|
|
|
|
|
12.50 (0.04) |
|
|
|
0.29 |
| NACM |
|
0.91 |
|
|
|
|
|
35.25 (0.03) |
|
|
|
0.80 |
| AAR |
|
0.79 |
|
|
|
|
|
26.47 (0.03) |
|
|
|
0.61 |
| LOT1 |
|
|
0.49 |
|
|
|
|
|
7.41 (0.07) |
|
|
0.24 |
| LOT4 |
|
|
0.41 |
|
|
|
|
|
5.95 (0.07) |
|
|
0.16 |
| LOT10 |
|
|
0.24 |
|
|
|
|
|
3.41 (0.07) |
|
|
0.06 |
| RLOT3 |
|
|
0.29 |
|
|
|
|
|
4.29 (0.07) |
|
|
0.09 |
| RLOT7 |
|
|
0.40 |
|
|
|
|
|
6.07 (0.07) |
|
|
0.16 |
| RLOT9 |
|
|
0.44 |
|
|
|
|
|
6.59 (0.07) |
|
|
0.20 |
| inTRA |
|
|
|
0.94 |
|
|
|
|
|
15.11 (0.06) |
|
0.89 |
| inTER |
|
|
|
0.67 |
|
|
|
|
|
12.55 (0.05) |
|
0.44 |
| PTGf1 |
|
|
|
|
0.82 |
|
|
|
|
|
40.58 (0.02) |
0.68 |
| PTGf2 |
|
|
|
|
0.86 |
|
|
|
|
|
48.87 (0.02) |
0.74 |
| PTGf3 |
|
|
|
|
0.88 |
|
|
|
|
|
56.47 (0.02) |
0.78 |
| PTGf4 |
|
|
|
|
0.76 |
|
|
|
|
|
30.31 (0.03) |
0.58 |
| PTGf5 |
|
|
|
|
0.76 |
|
|
|
|
|
29.69 (0.03) |
0.57 |
Note: Statistically significant p < .05 in bold; War = War events; PTSD = Post-Traumatic Stress Disorder; LOT = Optimism; RC = Religious Commitment; Growth = Post-Traumatic Growth
Figure 3. Standardized Estimates of the Final Model
R-square values showed that war accounted for 44% of the variance in PTSD; optimism accounted for 51% of the variance in religious commitment; and PTSD, optimism, and religious commitment accounted for 83% of the variance in PTG. As shown in Table 2, all goodness-of-fit indices for the revised model were in ideal parameters.
Table 2
Fit Indices and Modification of Theoretical Model (N = 350)
| Model |
χ2
|
df
|
Pr > χ2
|
Δ χ2
|
Δdf
|
CFI
|
SRMR
|
RMSEA
|
RMSEA CL90
|
| Baseline |
2697.77
|
210
|
< .0001
|
—
|
—
|
|
|
|
|
| Measurement Model (Mm) |
338.17
|
179
|
< .0001
|
2359.60
|
31
|
.936
|
0.056
|
0.050
|
(0.042-0.059)
|
| Theoretical Model (MT) |
347.65
|
179
|
< .0001
|
—
|
—
|
.932
|
0.062
|
0.052
|
(0.044-0.060)
|
| Modified Theoretical Model (MTm) |
292.98
|
176
|
< .0001
|
54.67
|
3
|
.953
|
0.049
|
0.044
|
(0.035-0.052)
|
Note: χ2 = chi square; df = degrees of freedom; CFI = Comparative Fit Index; SRMR = Standardized Root Mean Square Residual; RMSEA = Root Mean Square Error of Approximation; RMSEA CL90 = RMSEA 90% Confidence Limits
Discussion and Implications
Because participants were survivors of a 10-year war-related traumatic experience, it was unsurprising that the majority of them met the PTSD diagnosis (APA, 2013). Despite the time lapse, these participants exhibited signs of intrusion, avoidance, reckless behaviors, and hypervigilance. Because the majority of the participants had joint households (married, 30%; lived with partners, 23.6%), it is likely that their loved ones could struggle with secondary traumatization (Jenkins & Baird, 2002; Lahav et al., 2016). Any therapeutic intervention for a group like this must be systemic in nature (Gehart, 2017) to address the mental health issues of not just survivors, but also the significant people in their lives.
Moreover, results of the first hypothesis indicated that there was a statistically significant difference in PTG scores based on gender, with females reporting more growth than males. These results confirm research in both Western and non-Western samples using the PTGI as an instrument to assess psychological growth after a traumatic experience (Baker et al., 2008; Powell et al., 2003). The high Cronbach’s alpha of the PTGI within the sample suggests that the construct of growth is being measured consistently across samples. Thus, interventions used in Western samples to enhance growth, barring any cultural complications, could work in non-Western samples.
In addition, results of the SEM confirm that people with dispositional optimism have a higher chance of gaining growth after a traumatic event than people who are pessimistic (Broekhof et al., 2015; Peterson & Steen, 2012). Readers are cautioned in making this leap because this Western-based instrument used in the non-Western environment was not consistent in measuring the optimism construct (α < .70). It is however possible that had the statements not been negatively worded, participants’ responses would have been different. This assertion is confirmed by the improved theoretical model from covarying the errors of the negatively worded items in the optimism factor.
There is also evidence from the data that participants used their search for the sacred to grow from the war-related traumatic experiences. These results have implications for professional counselors and counselor educators. Counselor educators can train professional counselors to appropriately assess spirituality as part of their multicultural assessment. Because of spirituality’s ability to enhance growth, incorporating spiritual competencies with a therapeutic relationship could enhance post-trauma healing. However, there were no questions assessing participants’ use of religious commitment as a community or whether their use of religious commitment arose from the war-related experiences.
In a related study assessing religious commitment’s moderating effect on the relationship between trauma and growth, the researchers discovered a curvilinear moderating effect (Acquaye, Sivo, & Jones, in press). Thus, the higher participants’ religious commitment, the lower their PTG; at mid-religious commitment, there was increased PTG. These findings were not too far from Joseph’s (2011) supposition that increased religiousness did not automatically lead to increased growth. Therefore, when clients report growth, professional counselors should not assume this growth corresponds to increased religiousness. It may well be that for some clients, decreased religiousness will lead to increased growth (Barrington & Shakespeare-Finch, 2013).
Limitations and Suggestions for Future Research
Because of the group-like nature of data collection, participants communicated among themselves. This kind of communication could skew the results, especially if some participants are providing responses that are consistent with the majority narrative. If possible, future research could be done with more privacy and not in a group format.
On the other hand, this mode of data supports the recommendation that future work take a qualitative approach and identify participants’ perceptions about growth, religious commitment, and optimism. It is possible that even though reliability analyses supported the reliability of these instruments, participants’ opinions without the prompts in such surveys could have shed a new light onto what they perceived to be growth and optimism.
It would be enlightening to conduct a comparative study to examine those who are still living outside Liberia (e.g., in the United States) and those living within Liberia to explore whether optimism and religious commitment before or after the war played a part in PTG, depending on where a person currently resides. This comparative study could identify differences in both religious commitment and optimism scores between gender and family status, depending on current residence. Finally, the comparative study may identify current post-trauma (disorder and growth) scores and how these scores reflect outlook on life.
In sum, the hypothesis that between 10–50% of participants will meet the diagnostic criteria for PTSD was supported; 79.1% of participants met the diagnostic criteria for PTSD. Furthermore, the hypothesis that both males and females will exhibit co-occurring PTSD and PTG was partially supported. Even though there were no differences in PTSD scores between gender, females reported higher PTG scores than their male counterparts. The third hypothesis that those who report high optimism will have higher PTG scores was supported. Finally, the model also supported the hypothesis that people who reported higher religious commitment scores will have higher PTG scores, as well as the hypothesis that optimism, PTSD, and religious commitment could all predict PTG. Most of the instruments used were reliable enough to aver that the measurement of the constructs is cross-cultural.
Conflict of Interest and Funding Disclosure
Data collected in this study was part of a dissertation study. The dissertation was awarded the 2016 Dissertation Excellence Award by the National Board for Certified Counselors.
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Hannah E. Acquaye, NCC, is an assistant professor at Western Seminary. Correspondence can be addressed to Hannah Acquaye, 5511 SE Hawthorne Blvd., Portland, OR 97215, hacquaye@westernseminary.edu.
