Jul 11, 2017 | Volume 7 - Issue 3
Toni O. Davis, Keith A. Cates
Specialty courts, such as mental health courts, drug courts, and veterans treatment courts, were developed with the intention of reducing recidivism and obtaining better outcomes for participants selected from the particular populations served by each court. Efforts to improve the public good have produced a reimagining of the justice system with a focus on therapeutic jurisprudence and restorative justice. Counselors contract with the courts to provide therapeutic services that assist the courts in supplementing the more traditional court functions of punishment, corrections, and public safety. Mental health clinicians can fulfill pivotal roles in these courts as advocates, educators, and clinical technicians. This paper provides an introduction into specialty courts for counselors considering provision of clinical services in these still-developing areas.
Keywords: specialty courts, mental health courts, drug courts, veterans treatment courts, mental health counseling
In 1963, the passage of the Community Mental Health Centers Act (Feldman, 2003) led to the closing of most state psychiatric hospitals and the provision for providing services at the community level. However, the same act had the unintentional result of transferring patients with severe mental illness from psychiatric hospitals into jails and prisons (Farmer et al., 2017; Hnatow, 2015; Shenson, Dubler, & Michaels, 1990; Torrey et al., 2014). More recently, the war on drugs has exacerbated the problem of overcrowding in penal and justice systems ill-equipped to provide therapeutic services for these individuals (Hafemeister & George, 2012; Harvard Law Review, 1998; Torrey, 1997; Walsh & Holt, 1999). This predicament has led to the Cook County jail in Illinois being labeled as the country’s largest mental health institution (Hill, 2016).
In order to facilitate greater efficiency and effectiveness in the justice system for the populations encountered, specialty courts act to counter a system that historically has depersonalized individuals (Kleinfeld, 2016). Specialty courts identify common issues faced by particular populations and address the underlying causes of criminogenic behavior by focusing on the individual to produce better outcomes. Although mental health professionals fulfill pivotal roles in these courts, many counselors are unfamiliar with specialty courts. The purpose of this paper is to describe the specialty court movement and the roles of counselors within it.
The Justice System—Old and New
The justice system in America has traditionally been one of punitive action—to punish offenders and deter the tempted. Since the 1950s, America’s policies targeting illicit drug use have resulted in a large population of low-level offenders serving long, mandatory-minimum sentences, often with inadequate support and resulting in repeated contact with the traditional criminal justice system (Haley, 2016; Kupers, 2015).
Between 1968 and 1978, the number of patients in state mental hospitals fell 64%, while the census in state prisons rose 65% (Steadman, Monahan, Duffee, & Hartstone, 1984). In 2012, the number of prisoners diagnosed with mental illness exceeded 352,000, more than 10 times the number in state psychiatric hospitals (Torrey et al., 2014). In the absence of evidence that incarceration without treatment is in their own best interest, or that of society (Isaac & Armat, 1990; Kondrat, Rowe, & Sosinski, 2012), such prisoners are a burden on the limited resources of prison systems in every state.
The specialty court movement arose to address the specific needs of the mentally ill, drug offenders, and other populations, and to effect a decrease in the underlying causes of criminal behavior and thereby reduce the number of people incarcerated in jails and prisons. Specialty courts take the traditionally adversarial roles of prosecution and defense and turn them into cooperative roles to foster a therapeutic environment for those individuals who would benefit (Kondo, 2001). Veterans treatment courts are a more recent addition to the specialty court movement, joining mental health courts, drug courts, gun courts, domestic violence courts, and other specialized courts (Baldwin, 2016). Veterans treatment courts treat underlying causes of crime and other challenges faced by veterans and service members.
The Center for Court Innovation developed three organizing principles for specialty courts (Boldt, 2014). The first principle is a problem-solving orientation that identifies and addresses underlying causes of criminality common to specific groups; the second principle is cooperation with community resources offering treatment and oversight; and the third principle is accountability (Boldt, 2014). These principles work within the context of the two major approaches of specialty courts: therapeutic jurisprudence and restorative justice.
Two Working Approaches in Specialty Courts
The specialty court movement is based on two overarching approaches: therapeutic jurisprudence, which seeks improved outcomes for the individual facing charges; and restorative justice, which seeks restitution for all stakeholders.
Therapeutic jurisprudence promotes a wellness paradigm using the court as a therapeutic tool. Therapeutic jurisprudence takes the approach that it is in the best interest of society to work cooperatively with all stakeholders to provide better outcomes in criminal justice. The model is a new paradigm based on a cooperative and non-adversarial approach of judges, prosecutors, defense attorneys, and community and mental health professionals (Haley, 2016).
Restorative justice is the idea that justice is served by restoration, both to the individuals and to the community affected by crime. In traditional court settings, restoration includes financial restitution by the offender (to the victims) in addition to incarceration (for the public good). The Centre for Justice & Reconciliation has defined restorative justice as a process to heal harms and bring about transformation for all parties (Centre for Justice & Reconciliation, 2017). This is necessary because crime is more than simply breaking the law. Crime also causes people harm and hurts relationships and the community. Thus, a just response needs to address the harms as well as the wrongdoing (Centre for Justice & Reconciliation, 2017). Restorative justice in specialty courts focuses on treatment options for an individual’s issues, which promotes the restoration of the offender. Working with specialty courts allows mental health counselors to combine individual therapy with vocational counseling, oversight of community service for program participants, aftercare supervision, and mediation and arbitration with victims to emphasize accountability for the individual (Haley, 2016), impacting the restorative process for all stakeholders. Integrating the counselor’s toolbox with all of these challenges requires skill and patience.
Clinical Integration With Specialty Courts
Specialty courts are challenging for all stakeholders. Judges must transition from performing as adjudicators of justice to facilitators of treatment, and the clinician serves both the court and the program participants by providing treatment services. Counselors educate and advocate for participants and are able to frame program objectives into long-term treatment outcomes and participant prognoses for judges and court officers (Kupers, 2015). The mental health counselor, as a therapeutic service provider, becomes a de facto expert who the court relies on to assist in the development and implementation of treatment goals (Hughes & Peak, 2012).
Specialty courts are full of legal terminology, and counselors working with the court can assist in conveying meaning clearly to program participants. A better-informed client will be more able to give informed consent and have more buy-in to the process. Facilitating education for participants increases the likelihood of successful completion of the program, which in turn translates to an improved quality of life and reduction in re-arrest rates (Haley, 2016).
Participants in specialty courts will bring many issues to treatment. Counselors may provide assessments for the presence of mental health disorders, substance use, and social service needs, and they may be called upon to facilitate other assessments on an as-needed basis.
Jurisdiction for participants is an area with a large amount of variety from program to program. For individuals that may be eligible for different programs, placing their case under the jurisdiction of one specialty court over another becomes a question of resources. For example, some mental health courts are able to address the substance use issues of participants, while others are not (Fisler, 2015).
Specialty courts operate under the model of managed care, in which the treatment modalities are brief and evidence-based, such as with cognitive behavioral therapy (Kupers, 2015). The Council of State Governments outlined best practices for the creation of mental health courts (Thompson, Osher, & Tomasini-Joshi, 2007), which included behavioral modification techniques and operant conditioning as a key educational element, and included instruction on proper use of negative and positive reinforcement techniques (Russell, 2015). Judges and court officers are able to use the Council of State Governments’ model to structure their courts within the limitations of local resources and needs. Awareness of these needs and limitations allows the clinician to be more effective in influencing outcomes and program success for participants of specialty courts, of which three types are included in this discussion: drug courts, veterans treatment courts, and mental health courts.
Drug Courts
In 1989, a judge in Miami, Florida, started ordering drug users that came before the court into treatment in lieu of jail. Out of this was born the drug court, which has now become the model for specialty courts. The Miami court started as a response to the criminogenic life-cycle experienced by low-level offenders appearing before the court: substance use → crime → jail → release, then repeat (Fulkerson, 2009). The effect of the new paradigm on the cycle became: substance use → crime → treatment → support and supervision, leading to reduced recidivism (Haley, 2016). Since that time, drug courts have quickly spread across the nation. By 2001, there were more than 700 drug courts in the United States (Harrison & Scarpitti, 2002) and 1,600 as of 2010 (Haley, 2016).
Drug courts use supervision and monitoring to ensure compliance to program requirements. Counselors serve as agents of the court, verifying adherence through substance abuse treatment services, drug testing, talk therapy, and encouraging abstinence as a condition to successful completion. Counselors working with drug court participants face a rather straightforward challenge, in which compliance to program requirements and overall program success can be quantified through drug testing and analysis of available data, including re-arrest rates. More complicated are issues facing participants in other specialty courts, such as the veterans treatment courts.
Veterans Treatment Courts
As of 2010, the United States had deployed approximately 1.9 million service members to serve in Afghanistan and Iraq (Rizzo et al., 2011). Conflicts from the Middle East have left the United States with over 40,000 wounded (Rizzo et al., 2011) and over 350,000 service members with traumatic brain injury (Baldwin, 2016). As the United States continues to conduct military operations around the world, the need exists to address the specific concerns of veterans returning to non-combat duties. Veterans treatment courts (VTCs) are now addressing, via the drug court model, various needs of this population (Slattery, Dugger, Lamb, & Williams, 2013). The first VTC was established in 2004 in Anchorage, Alaska, but the model from which most programs are built is the one established in Buffalo, New York, in 2007–2008 (Baldwin, 2016).
Issues the counselor may face with participants in VTCs include post-traumatic stress disorder, substance use, military sexual trauma, major depression, and neuropsychological problems (Eisen et al., 2012), as well as homelessness and unemployment issues (Baldwin, 2016). In addition to services available to participants in other specialty courts, VTCs are designed and built recognizing differing needs of supervision and support, including cooperation with the Veterans Administration (VA) and other service members (Russell, 2015). Connections the VTCs have through the VA make a difference for participants, who rely heavily on the VA for benefits. VA connections cannot easily be replaced or replicated and are scarce in many locales (Clark, McGuire, & Blue-Howells, 2014).
VTCs also differ from many other specialty courts in that they have a peer-mentoring component. Mentoring is the use of previous program participants and other service members in a peer-support role, similar to their use in 12-step programs as part of a successful drug treatment protocol. Mentoring is more important for this population because of the military’s highly structured culture and the importance of respect for others with military experience (Clark et al., 2014; Russell, 2015).
Like other specialty courts, VTCs have some variance in those eligible for participation. VTCs often limit participation to those with certain mental health diagnoses or substance abuse issues and to those who are not charged with a felony or violent crime. Eligibility also may be restricted to only those deployed to a combat zone or only those who are eligible for VA benefits.
Funding for VTCs is different than that of other specialty courts, which rely on local sources of funding. VTCs get most of their funding through the VA (Russell, 2015), which operates through strict guidelines. In fact, VA guidelines currently limit the role of counselors, preferring instead services performed by psychiatrists and psychologists—a slightly different perspective than one seen in mental health courts.
Mental Health Courts
The first mental health court was introduced in the late 1990s in Broward County, Florida (Linhorst et al., 2009), and by 2010 there were over 200 operating in the United States (Fisler, 2015; Hughes & Peak, 2012). Individuals enter the court system through arrest, usually for minor offenses (Hnatow, 2015; Walsh & Holt, 1999). Mental health courts differ from drug courts in the wider variety of conditions that must be addressed and the greater degree of treatment individualization available for participants. More robust measurement of program success is required as well. In drug court, success can be measured by length of time spent in sobriety. In mental health court, the variety of illnesses and conditions specific to the individual requires more advanced assessment and occurs in the arena of a team approach, with counselor, case manager, psychologist, and court administration involved in the process.
Again, there is variance in the design and operation of mental health courts. The Council of State Governments’ document begins with the assumption that mental health courts are designed with the cooperation of a variety of individual stakeholders, all of whom may bring a wide range of goals with them (Fisler, 2015). The focus on public safety and court jurisdiction means eligibility criteria is again an issue. Most programs exclude individuals facing charges for felonies and violent crimes (Linhorst et al., 2009).
Counselors working with mental health courts have great influence on participant eligibility, as well as treatment options. Counselors work to inform participants of the risks of participation, potential benefits, their rights and responsibilities, requirements of successful program completion, and any ramifications of program failure. Again, counselors who are able to communicate clearly with participants can develop the rapport needed for buy-in and informed consent. With specialty court familiarity, counselors can address concerns and considerations.
Clinical Concerns and Considerations
Confidentiality and Privacy
Kupers (2015) advocated for the need to keep interventions confidential and private. Specialty court participants’ hearings before a judge should be segregated from regular court proceedings and entered in the specialty court docket (the list of cases to be tried). This may mean that all participants be placed on dockets in a separate courtroom and, if possible, in separate locations. Public mingling with individuals awaiting their turn on the docket represents an all-too-real possibility of the loss of confidentiality and privacy.
Up-front disclosure of the limits of confidentiality will lead to a participant more able to give informed consent, a deeper rapport with clients, and greater diligence on the part of the counselor (Kupers, 2015). In an era of multidisciplinary teams, confidentiality requirements must be rigorous. As with regular notes, counselors’ and case managers’ personal notes need segregation from formal notes used in treatment. Case managers should keep specific treatment information separate from court files, and if an individual fails the program or withdraws, transfer documents used by the court should be created using general treatment information to ensure confidentiality (Linhorst et al., 2009).
Consistency of Programs
Consistency is an issue surrounding all areas of specialty court programs. One concern lies within law enforcement. The primary point of contact between an individual with mental illness and the justice system is often police or the county sheriff (Walsh & Holt, 1999). Having the ability to divert a person during daily operations, law enforcement benefits the most from training to identify and work with the mentally ill. In their survey of Virginia sheriffs, Walsh and Holt (1999) found that the majority of sheriffs received little or no instruction on working with individuals with mental illness.
More available training serves the public by providing more capable officers. Officers with experience and training in the diverse expression of mental illness and substance use are better able to recognize an individual in need or in crisis, with better outcomes (Ogloff et al., 2012). Overall, officers trained to deal more appropriately with detainees can reduce inappropriate incarceration, use of emergency services, recidivism, and cost to communities (Hnatow, 2015).
Consistency is necessary for fair and uniform needs assessments. Proper assessment is a cooperative process, requiring diligent coordination between counselors, case managers, and court officers. Regular meetings with stakeholders will promote assessment service needs, availability of services and costs, location and acquisition of funding, and specification of outcomes and outcome measurements (Walsh & Holt, 1999). With training and assessment addressed, counselors can direct more energy to advocacy needs.
Advocacy
Counselors have a duty to educate and advocate for the communities with which they interact and the American Counseling Association (2003) is fully in support of this ideal. On the surface, this may appear to be in opposition to the demands of working in the arena of specialty courts, but counselors are in an ideal situation to promote better outcomes for clients through advocacy efforts (Grob, 1995; Kupers, 2015).
By providing services to participants and advocating for programs, counselors working with specialty courts not only actively serve client needs, but also provide ethical and pragmatic examples of conduct for those considering service to these populations. Linhorst et al. (2009) also noted that counselor participation contributes to the development of best practices for the courts.
Conclusion
Specialty courts represent a new frontier for counselors. As mental health experts, counselors are the key to successful outcomes for participants (Linhorst et al., 2009). The need for cooperation and coordination by stakeholders with opposing goals and objectives and the increased scrutiny of treatment are challenges that await counselors with the courage to work with participant populations within specialty courts. The rewards of seeing change and improvement in participants’ lives far outweigh the concerns of operating in these still-developing areas.
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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Toni O. Davis is a graduate student at Troy University. Keith A. Cates, NCC, is an associate professor at Troy University. Correspondence can be addressed to Toni Davis, #368 Hawkins Hall, Troy University, Troy, AL 36082, badaxe824@yahoo.com.
Jun 18, 2017 | Volume 7 - Issue 3
Jessica Z. Taylor, Susan Kashubeck-West
This study examined preferences for counseling topics to discuss in individual, group, and family counseling among young adults with cancer, as well as their ranked preferences for attending individual, group, and family counseling. A sample of 320 young adults with cancer (18–39 years old) completed an online survey containing items relevant to young adults’ psychosocial needs. Participants rated anxiety, finances, sad feelings, sexual and intimacy concerns, and stress management as most helpful for individual counseling; finding social support and getting information about one’s medical situation as most helpful for group counseling; and no topics as most helpful for family counseling. Participants rated individual counseling as their primary choice of counseling modality, followed by group counseling, and lastly family counseling. Counselors may help young adult clients by familiarizing themselves with the unique experience of being diagnosed with cancer at an early age, as well as providing age-specific in-person support and counseling group opportunities.
Keywords: cancer, young adult, counseling preferences, counseling modality, psychosocial needs
The leading disease-related cause of death for adolescents and young adults is cancer, with almost 70,000 individuals newly diagnosed each year (Nass et al., 2015). Adolescents and young adults with cancer have specific psychosocial needs that are not the same as those of adults with cancer, yet we know comparatively little about those needs. In 2006, the National Cancer Institute called for research on the specific psychosocial needs of adolescents and young adults diagnosed with cancer. In 2013, an Institute of Medicine workshop reviewed the progress made since 2006 and reported that many challenges remained (Nass et al., 2015). Zebrack (2011) stated that developing age-appropriate support services would benefit adolescents’ and young adults’ psychosocial well-being. For young adults with cancer, having a counselor that is knowledgeable about their unique psychosocial needs is especially important (Katz, 2015). Psychosocial needs and concerns related to quality of life may include relationships with others, emotions, body image, and spirituality (Sodergren et al., 2017). Indeed, young adults with cancer experience psychosocial and supportive care needs that are “not only unique to their age group but also broader in scope and more intense than those at any other time in life” (Bleyer & Barr, 2009, p. 204). These individuals need to be a priority for counseling researchers, and we should be attuned to young adults’ particular psychosocial needs and desires for counseling to help them as much as possible (Kumar & Schapira, 2013). Therefore, this study was designed to examine the perceived counseling needs of young adults with cancer.
We focused on individuals aged 18–39 because they have been shown to be developmentally different from adolescents (e.g., Arnett, 2000) and because they often have been lumped in with adolescents in research on their mental health needs (Haase & Phillips, 2004; National Cancer Institute, 2006). Although there are some similarities between adolescents and young adults with cancer in terms of psychosocial needs (Husson et al., 2017; Nass et al., 2015; Sender & Zabokrtsky, 2015; Sodergren et al., 2017), a growing discussion emphasizes the importance of exploring psychosocial needs across developmental age groups within the adolescent and young adult age range. This discussion especially focuses on the need for developing appropriate counseling and other psychosocial services (Fasciano, Souza, Braun, & Trevino, 2015; Iannarino, Scott, & Shaunfield, 2017; Katz, 2014, 2015; Salsman et al., 2014; Smith et al., 2013).
Generally, literature addressing the mental health needs and service usage of individuals with cancer is more abundant for older adults and for young adult survivors of childhood cancer, rather than for young adults diagnosed with cancer between the ages of 18 and 39 (Rabin, Simpson, Morrow, & Pinto, 2011). The research on the mental health needs of and service usage by adult cancer survivors older than 40 years of age suggests that they have a lower desire for, and utilization of, counseling services than do young adults with cancer (Gadalla, 2007; Hewitt & Rowland, 2002; Mosher et al., 2014). This need is largely unmet in the young adult population, in part because they may encounter difficulties affording counseling services (Hewitt & Rowland, 2002) or locating counseling services designed specifically for young adults with cancer (Marris, Morgan, & Stark, 2011; Zebrack, 2009).
Furthermore, there has been little research on the topics young adults with cancer would find beneficial to discuss in counseling or on the counseling modalities in which young adults with cancer would like to discuss specific topics. The current study’s authors previously conducted the first-known study (Taylor & Kashubeck-West, 2013) to ask young adults with cancer to rate the helpfulness of specific topics of discussion across different counseling modalities (i.e., individual, group, and family counseling). A sample of 151 young adults with cancer rated 11 items as helpful to discuss in individual counseling: (a) stress management and/or anxiety; (b) putting your own needs before others’ needs; (c) negative self-talk and sad feelings; (d) positive thinking; (e) living day to day; (f) trying to live a “normal” life; (g) finances; (h) partner concerns; (i) sexual and intimacy concerns; (j) finding social support; and (k) concerns with family. Participants identified the topic of trying to live a “normal” life as the most helpful individual counseling topic and alcohol or drug use as the least helpful topic of discussion. Within-group differences were found in that emerging adults (i.e., between the ages of 18–29 [Arnett, 2000]) rated the topic regarding thoughts about continuing or resuming education as significantly more helpful to discuss in individual counseling than did young adults (i.e., between the ages of 30–39 [Arnett, 2000]). Young adults rated the topic regarding partner concerns as significantly more helpful to discuss in individual counseling than did emerging adults. These findings seem to reflect age-related developmental tasks.
Taylor and Kashubeck-West (2013) also found that when asked to rate helpful topics for group counseling, young adults with cancer rated six topics on a group counseling needs assessment as helpful to discuss in group counseling with other young adults with cancer: (a) talking about feelings; (b) sharing medical information; (c) finding different ways to think about and cope with the experience; (d) finding meaning and purpose from the experience; (e) discussing concerns about intimate relationships; and (f) discussing concerns about casual relationships. These findings are consistent with Zebrack, Bleyer, Albritton, Medearis, and Tang (2006), who found that young adults with cancer ranked the opportunity to meet other young adults with cancer as being one of their top supportive care needs, regardless of whether young adults with cancer were currently receiving or had completed medical treatment.
Young adults with cancer may attempt to protect the feelings of family members and others by not wanting to discuss their diagnosis or negative feelings about it (Hilton, Emslie, Hunt, Chapple, & Ziebland, 2009; MacCormack et al., 2001), suggesting a hesitancy to fully utilize family counseling. When Taylor and Kashubeck-West (2013) asked participants to rate how helpful 19 different topics would be to discuss in family counseling, only two topics were rated as being helpful: stress management and accepting the new “normal.” Not only did young adults with cancer rate the fewest items as helpful to discuss in family counseling, dating concerns—a relational topic—was identified as the topic young adults with cancer least wanted to discuss in family counseling. Developmentally, as young adults with cancer work to gain independence from their family (Arnett, 2000), they may not see family counseling as an appealing option for supportive care.
The purpose of this study was to further examine the preferences of young adults with cancer for counseling topics and counseling modalities. This study builds on the 2013 study by Taylor and Kashubeck-West by using a larger sample of young adults with cancer, recruiting from a greater number of sources, and including more psychosocial concerns relevant to young adults with cancer using a counseling needs assessment tool. In extending previous exploratory work on this topic, this descriptive study had two primary goals: (a) to gain greater clarity of young adults’ preferences for topics to discuss in individual, group, and family counseling; and (b) to understand young adults’ preferences for these three counseling modalities. The results of this study provide counselors with helpful information as they attempt to meet the counseling needs of young adults with cancer.
Method
Participants
Participants were 320 young adults with cancer currently between the ages of 18 and 39, initially diagnosed with cancer at age 18 or older, and living in the United States. Descriptive analyses (see Table 1) showed that a majority of the sample identified as female (86%), Caucasian/White (87%), and heterosexual (94%). The mean age of the sample was 31.17 years old (range 18–39 years; SD = 5.14). A majority of participants were partnered or in a committed relationship (68%), 71% had obtained at least an undergraduate degree, and 66% were currently employed, with approximately 17% unemployed and 17% on medical or disability leave. Participants in the sample reported living in 41 states and Washington, D.C.
Approximately half of the participants (51%) reported that they had received counseling from a mental health professional (e.g., counselor, social worker, psychologist, psychiatrist, pastor, or priest) since their initial cancer diagnosis. A majority of participants (66%) had tried to find a local in-person support group for young adults initially diagnosed with cancer during young adulthood, but less than half (48%) were successful in finding a local group.
On average, participants in the current sample were initially diagnosed with cancer at 27.76 years old (range 18–38 years; SD = 5.34). Participants reported 26 different initial cancer diagnoses, with seven diagnoses being reported more frequently: (a) Breast (29%), (b) Brain (16%), (c) Hodgkin’s Lymphoma (10%), (d) Thyroid (10%), (e) Leukemia (8%), (f) Non-Hodgkin’s Lymphoma (7%), and (g) Testicular (5%). A majority of participants (70%) reported they had completed medical treatment; 29% were currently receiving medical treatment. Of participants who had completed medical treatment, the mean number of months since completing treatment was 32.68 (range 0–192; SD = 36.31).
Most participants (78%) reported no recurrence of cancer. Of those who did have a recurrence (n = 69), the mean age at recurrence was 30.00 years old (range 19–38 years; SD = 5.44) and the mean duration of time between initial cancer diagnosis and recurrence was 2.06 years (range 0–10 years; SD = 1.88).
Procedure
All study procedures were approved by the university Institutional Review Board. Participants were recruited from cancer organizations based in the United States relevant to young adults with
Table 1
Characteristics of Study Participants (N = 320)
Gender
Male 45 (14.1)
Female 275 (85.9)
Race/Ethnicityb
Caucasian/White 279 (87.2)
African American/Black 10 (3.1)
Asian American 11 (3.4)
Hispanic/Latina(o) 28 (8.8)
Native American 3 (0.9)
Other 5 (1.6)
Current Socioeconomic Status
Lower Class/Working Class 52 (16.3)
Lower Middle Class 73 (22.9)
Middle Class 148 (46.4)
Upper Middle Class 42 (13.2)
Upper Class 4 (1.3)
Sexual Orientation
Heterosexual 297 (94.3)
Bisexual 12 (3.8)
Gay/Lesbian 6 (1.9)
Highest Level of Education
Did Not Complete High School 1 (0.3)
Completed High School/GED 13 (4.1)
Some College 77 (24.1)
Obtained Undergraduate Degree 122 (38.2)
Some Graduate School 31 (9.7)
Obtained Master’s Degree 63 (19.7)
Obtained a Doctorate 12 (3.8)
Stage/Grade of Initial Cancer Diagnosis
0 23 (7.5)
1 75 (24.5)
2 108 (35.3)
3 70 (22.9)
4 30 (9.8)
Note. a Totals do not equal 320 because of missing data. b Percentages greater than 100% because of participants being able to select from more than one category. cancer and with an online social media presence. Organizations were asked to post a recruitment solicitation for this study on the organization’s Facebook and Twitter social media websites. In addition to a convenience sample, snowball sampling was used. The recruitment postings invited potential participants to send the study information to other young adults with cancer. Professional contacts with access to young adults with cancer (e.g., cancer support organization program directors, cancer-related non-profit executive directors, and academic professionals with expertise in psychosocial issues experienced by individuals with cancer) also were asked to invite young adults with cancer to participate. Upon completion, participants were invited to participate in a raffle separate from the study survey for one of 20 randomly chosen $10 gift certificates to Amazon.com. Counseling needs assessment items were presented in random order within counseling modality to prevent systematic order effects; similarly, counseling modality was presented randomly.
Measures
Counseling needs assessment. Based on a review of the literature and feedback from two young adults with cancer, Taylor and Kashubeck-West (2013) developed three counseling needs assessment tools to explore topics that young adults with cancer might find helpful to discuss in individual, group, and family counseling. Their individual counseling needs assessment contained 31 items (Cronbach alpha = .91), their group counseling needs assessment contained 6 items (Cronbach alpha = .80), and their family counseling needs assessment contained 19 items (Cronbach alpha = .86). Comparisons of topic helpfulness between counseling modalities was limited because of the needs assessments containing different items.
The current study revised Taylor and Kashubeck-West’s (2013) counseling needs assessments into one counseling needs assessment that was used to explore topic helpfulness for each counseling modality to better allow for topic comparisons. Reviewing the literature, soliciting feedback from psychosocial oncology mental health and nursing experts, and consulting with young adults with cancer led to the revised 38-item counseling needs assessment used in the current study. Participants were asked to rate their perception of how helpful each of 38 topics would be to discuss in individual counseling, group counseling, and family counseling. Individual counseling was defined as “attending counseling by yourself” (Cronbach alpha = .96); group counseling was defined as “attending counseling with people you have never met before who also have been diagnosed with cancer between the ages of 18–39 and are currently between the ages of 18–39” (Cronbach alpha = .97); and family counseling was defined as “attending counseling with someone you personally know” (Cronbach alpha = .98). Participants selected their responses on a Likert-based scale ranging from 1 (very unhelpful) to 3 (neither helpful nor unhelpful) to 5 (very helpful) for each of the three counseling modalities. Finally, participants were asked to rank their preferences for counseling modalities, with 1 being their most preferred counseling modality and 3 being their least preferred.
Demographic items. Participants were asked to report their age, gender, race/ethnicity, relationship status, sexual orientation, and current socioeconomic status. Additionally, they were asked about their medical treatment status—whether they were currently in medical treatment for their cancer diagnosis or if they had completed medical treatment—as well as how many months it had been since they completed medical treatment, if applicable. Participants were asked if they had received counseling since their initial cancer diagnosis and whether they had tried to find a local, in-person support group specifically for young adults with cancer. If they had tried to locate a local in-person young adults with cancer group, participants were asked if they had been successful in finding one.
Results
The first goal of this study was to explore the perceived helpfulness of topics for young adults with cancer to discuss in individual counseling, group counseling, and family counseling. A mean helpfulness rating of 3.50 or greater on a 1 to 5 Likert-based scale—on which 3.0 was neither helpful nor unhelpful—was selected as indicating that a topic was rated as helpful to discuss in counseling. Individual counseling and group counseling both had 25 topics rated as helpful, and family counseling had 12 topics rated as helpful. Thus, participants found more than twice as many topics helpful for discussion in individual and group counseling compared to family counseling. See Table 2 for average helpfulness ratings by topic across the three counseling modalities.
Table 2
Mean Differences Between Counseling Topics Across Counseling Modalities and ANOVA Results
Individual Group Family
Variable M (SD) M (SD) M (SD) N F h2 Power
1. Accepting the new “normal”a 4.15a (.99) 4.22a (.96) 3.86b (1.14) 286 21.76*** .07 1.00
2. Alcohol or drug use 2.65a (1.34) 2.70a (1.29) 2.49b (1.21) 287 5.98** .02 .88
3. Anxietya 4.19a (.99) 4.03b (1.06) 3.77c (1.18) 283 26.39*** .09 1.00
4. Being accepted by others 3.55a (1.14) 3.63a (1.17) 3.26b (1.16) 282 17.30*** .06 1.00
5. Concerns with child(ren)a 3.30a (1.33) 3.30a (1.33) 3.22a (1.41) 280 .92 <.01 .21
6. Concerns with family members 3.45a (1.21) 3.37a (1.22) 3.37a (1.26) 283 .79 <.01 .19
other than partner, parent(s),
sibling(s), or child(ren)
7. Concerns with friend(s) 3.68a (1.07) 3.69a (1.07) 3.35b (1.16) 283 17.50*** .06 1.00
8. Concerns with parent(s)a 3.57a (1.18) 3.50ab (1.22) 3.39b (1.22) 285 3.83* .01 .69
9. Concerns with partner 3.67a (1.21) 3.53ab (1.25) 3.43b (1.28) 288 6.27** .02 .90
10. Concerns with sibling(s) 3.33a (1.22) 3.21a (1.26) 3.24a (1.22) 285 2.04 .01 .42
11. Creating a memorable 3.28a (1.23) 3.29a (1.23) 3.18a (1.27) 285 1.92 .01 .39
document of your life
for yourselfa
12. Creating a memorable 3.34a (1.23) 3.32a (1.21) 3.25a (1.27) 286 1.00 <.01 .22
document of your life to share
with loved onesa
13. Dating concernsa 3.11a (1.43) 3.15a (1.44) 2.65b (1.33) 284 28.97*** .09 1.00
14. Finances 3.82a (1.13) 3.65b (1.21) 3.60b (1.25) 285 6.10** .02 .89
15. Finding meaning in lifea 3.61a (1.18) 3.57a (1.17) 3.35b (1.19) 283 10.35*** .04 .99
16. Finding purpose in life 3.60a (1.15) 3.59a (1.17) 3.33b (1.17) 284 12.36*** .04 1.00
17. Finding social support 3.84a (1.08) 4.05b (.99) 3.58c (1.19) 282 24.59*** .08 1.00
18. Finding/making meaning 3.70a (1.10) 3.73a (1.13) 3.48b (1.21) 281 8.91*** .03 .97
from your diagnosisa
19. Getting information about 3.52a (1.17) 3.77b (1.13) 3.51a (1.23) 288 10.55*** .04 .99
your medical situation
20. How and what to tell your 3.16a (1.37) 3.27a (1.31) 3.18a (1.39) 282 2.18 .01 .45
child(ren) about your situation
21. Infertility issues 3.55a (1.35) 3.50a (1.35) 3.17b (1.44) 286 19.01*** .06 1.00
22. Insurance issues 3.63a (1.20) 3.56ab (1.25) 3.40b (1.29) 288 6.09** .02 .89
23. Job situation 3.70a (1.20) 3.55a (1.22) 3.29b (1.24) 286 18.39*** .06 1.00
24. Living day to day 3.78a (1.13) 3.85a (1.13) 3.62b (1.16) 285 6.50** .02 .91
25. Making memories for your 3.37a (1.20) 3.35a (1.24) 3.33a (1.34) 284 .17 <.01 .08
child(ren)/partner/family to have
26. Negative self-talk 3.68a (1.24) 3.68a (1.15) 3.36b (1.20) 283 15.46*** .05 1.00
27. Pacing yourself to prevent
exhaustiona 3.74a (1.14) 3.80a (1.11) 3.52b (1.20) 287 12.27*** .04 1.00
28. Pain and its effect on your life 3.66a (1.11) 3.71a (1.15) 3.47b (1.23) 285 8.82*** .03 .97
29. Positive thinkinga 3.99a (1.03) 3.97a (1.02) 3.72b (1.10) 286 12.88*** .04 1.00
30. Putting your own needs 3.86a (.99) 3.79a (1.02) 3.55b (1.14) 287 15.38*** .05 1.00
before others’ needs
31. Sad feelingsa 4.08a (1.01) 3.85b (1.08) 3.62c (1.19) 288 27.90*** .09 1.00
32. Sexual/intimacy concernsa 3.87a (1.10) 3.44b (1.31) 3.31b (1.38) 286 26.93*** .09 1.00
33. Spiritualitya 3.25a (1.23) 3.25a (1.27) 3.12a (1.21) 284 2.92 .01 .56
34. Stress managementa 4.22a (.97) 4.09b (1.00) 3.84c (1.15) 288 22.78*** .07 1.00
35. Talking more effectively with 3.74a (1.16) 3.79a (1.11) 3.51b (1.24) 288 10.83*** .04 .99
health care professionals
regarding your physical condition
36. Thoughts about 3.32a (1.20) 3.32a (1.23) 3.09b (1.25) 288 10.36*** .04 .99
continuing/resuming education
37. Trusting the doctora 3.45acd (1.17) 3.55ac (1.15) 3.33bcd (1.20) 286 7.31** .03 .93
38. Will/advanced directive concernsa 3.39a (1.18) 3.26a (1.21) 3.33a (1.19) 287 1.83 .01 .38
Note. Power = observed power at α < .05. Means sharing a common subscript are not statistically different at p < .05 according to Bonferroni pairwise comparison tests.
a Greenhouse-Geisser correction utilized for violation of Mauchly’s Test of Sphericity at p < .05 * p < .05; ** p < .01; *** p < .001
Next, we compared participants’ ratings of counseling topic helpfulness among the three counseling modalities. A two-way within-subjects multivariate analysis of variance (MANOVA) was conducted to assess the interaction effect of counseling topic and counseling modality. There was a significant multivariate interaction effect: Pillai’s V = .59, F(74, 144) = 2.77, p < .001, η2 = .59, observed power = 1.00. Given this significant multivariate interaction effect, a one-way within-subjects analysis of variance (ANOVA) was conducted for each of the 38 counseling topics included on the counseling needs assessment tool to better understand which topics were perceived as more helpful to discuss in certain counseling modalities (see Table 2 for ANOVA results).
Participants rated five topics as significantly more helpful to discuss in individual counseling than in the other two counseling modalities: (a) anxiety, (b) finances, (c) sad feelings, (d) sexual and intimacy concerns, and (e) stress management. The two topics (a) finding social support and (b) getting information about your medical situation were rated as being significantly more helpful to discuss in group counseling versus the other two counseling modalities. Finally, participants rated three topics as significantly more helpful to discuss in individual counseling than in family counseling: (a) concerns with parent(s), (b) concerns with partner, and (c) insurance issues. No topics were rated as significantly more helpful to discuss in family counseling than in individual or group counseling.
The second goal of this study was to examine whether there were differences in young adults’ counseling modality preferences. Frequencies and percentages for counseling modality preferences can be found in Table 3. A majority of participants selected individual counseling as their first choice for counseling modality (73%), followed by group counseling (21%), and, finally, family counseling (7%). For second choice, the highest frequency of participants selected group counseling (45%), followed by family counseling (35%), and lastly, individual counseling (21%). For participants’ third choice, family counseling was selected most frequently (59%), followed by group counseling (35%), and lastly, individual counseling (6%).
Table 3
Counseling Modality Preferences (N = 296)
First Choice
Individual Counseling 215 (72.6)
Group Counseling 61 (20.6)
Family Counseling 20 (6.8)
Second Choice
Individual Counseling 62 (20.9)
Group Counseling 132 (44.6)
Family Counseling 102 (34.5)
Third Choice
Individual Counseling 19 (6.4)
Group Counseling 103 (34.8)
Family Counseling 174 (58.8)
To explore whether significant differences existed among rankings of preferences for counseling modalities, a one-way within-subjects ANOVA was conducted. In conducting the analysis, Mauchly’s Test of Sphericity was statistically significant (W = .93, p <.001), indicating heterogeneity of covariance matrices across levels of preference rankings for counseling modalities (Meyers, Gamst, & Guarino, 2006). Therefore, a Greenhouse-Geisser correction was utilized for interpreting results. The observed F value was statistically significant: F(1.87, 551.48) = 169.30, p < .001, η2 = .37, observed power = 1.00. Bonferroni pairwise comparison tests (p < .05) demonstrated that participants ranked individual counseling (M = 1.34, SD = .59) significantly higher than group counseling (M = 2.14, SD = .73), which in turn received a significantly higher ranking than family counseling (M = 2.52, SD = .62). Thus, participants ranked attending individual counseling as their first preference for counseling modality, followed by group counseling ranked as their second preference, and finally family counseling ranked as their last preference.
Discussion
The purpose of this study was to further examine the perceived counseling needs of young adults with cancer with regard to counseling. A paucity of research has studied counseling topic and modality preferences for young adult clients with cancer in depth. Both individual and group counseling had the same number of topics rated as helpful (25/38 topics), and 15 topics were rated as being equally helpful in group or individual counseling. Many of the 15 topics are discussed in the literature as relevant to young adults with cancer: infertility concerns (Eiser, Penn, Katz, & Barr, 2009; Gupta, Edelstein, Albert-Green, & D’Agostino, 2013; Katz, 2015; Kent et al., 2012), the “new normal” (Miedema, Hamilton, & Easley, 2007; Odo & Potter, 2009; Snöbohm, Friedrichsen, & Heiwe, 2010), employment (Katz, 2015; Odo & Potter, 2009; Zebrack, 2011), and pacing oneself to prevent exhaustion (Hauken, Larsen, & Holsen, 2013; Odo & Potter, 2009; Snöbohm et al., 2010), among other developmentally relevant topics. Participants indicated that discussing anxiety, finances, sad feelings, sexual and intimacy concerns, and stress management in individual counseling would be significantly more helpful than discussing these topics in group counseling or family counseling. Perhaps because these topics are fairly unique to one’s specific life context, they may not be topics that would be as helpful to discuss with other family members or with other young adults with cancer. They may be topics that young adults with cancer prefer to gain insight about on their own, with a counselor providing feedback. Alternatively, they may be topics that are perceived as being too sensitive to discuss with others. Especially in regard to financial concerns or sad feelings, perhaps young adults with cancer do not want to worry or burden friends and family with their concerns (Brennan, 2004; MacCormack et al., 2001).
Participants rated the topics of finding social support and getting information about one’s medical situation as significantly more helpful for discussion in group counseling than in individual or family counseling. Group counseling itself can be a way for young adults with cancer to find social support from others who understand their experiences (Kent et al., 2013). In addition, young adults with cancer may use group counseling to solicit advice and brainstorm ideas of how they can enhance their social support system. Even if someone is from a different background, such as a different social class, that person may be able to provide relevant information for increasing social support and interacting with one’s support system. Similarly, getting information about one’s medical situation is a topic that is not as context-specific as some of the topics rated as helpful to discuss in individual counseling (e.g., finances). Speaking with other young adults with cancer about one’s medical experience and soliciting information about their medical experiences may be beneficial.
Consistent with Taylor and Kashubeck-West’s (2013) findings, family counseling did not have any topics that were rated as more helpful to discuss in family counseling than in the other two counseling modalities. In addition, a few notable instances of family-relevant topics were rated significantly more helpful for discussion in individual counseling than in family counseling. These topics included discussing concerns about one’s parents, concerns about one’s partner, and insurance issues. Although the topics discussing concerns with parents or with a partner may seem best suited for discussion in family or couples counseling, young adults with cancer were significantly more interested in discussing these concerns in individual counseling. Perhaps young adults with cancer do not want to appear ungrateful to others and would prefer to utilize individual counseling as a way to express frustration or as a way to consider alternative ways of interaction. This possibility would be consistent with MacCormack et al.’s (2001) finding that adult cancer survivors tend to prefer discussing concerns regarding family members in individual counseling rather than in family counseling.
This study also explored how young adults with cancer would rank preferences for counseling modality. Descriptive frequencies indicated that a strong majority of participants (73%) chose individual counseling as their first choice of counseling modality over group counseling or family counseling. Examining helpful counseling topics may be beneficial in understanding this result. Topics rated as more helpful to discuss in individual counseling than in other forms of counseling tended to be topics more specific to one’s life context, such as financial concerns. Additionally, the topics involved feelings that may be perceived as negative feelings, such as anxiety, sadness, and stress. Topics chosen as most helpful to discuss in group counseling did not share the same underlying affective nature, but were related more to asking other young adults with cancer for their advice, experiences, and support. Counselors and other professionals should consider young adults’ emotional state and purpose for attending counseling when recommending utilization of individual or group counseling. This study provides evidence that young adults with cancer do not particularly prefer family counseling or feel that discussing many topics in family counseling would be helpful. Developmental tasks during young adulthood, such as gaining independence from one’s family of origin, may contribute to this.
Implications for Counselors
Because participants in this study selected individual counseling as their first choice for counseling modality, counselors need to familiarize themselves with what young adults with cancer may want to discuss in individual counseling, as well as how a young adult may experience a cancer diagnosis during young adulthood. Katz’s (2014, 2015) two books focusing on the psychosocial lived experience of young adults with cancer would be a beneficial starting point for counselors to familiarize themselves with relevant issues. When first exploring the concerns of clients who are young adults with cancer, counselors can begin by examining relevant developmental concerns related to the five counseling topics young adults with cancer in this study rated as being most helpful to discuss in individual counseling. Because the identified helpful topics relate primarily to emotions, an emotion-focused therapeutic approach (Greenberg, 2004) may be beneficial for young adult clients. Taylor, Hutchison, and Cottone (2013) reviewed three existentially based individual counseling models for adult cancer survivors that counselors may consider based on their young adult clients’ needs: (a) dignity therapy, (b) meaning-making intervention, and (c) short-term life review.
An implication of this study for counselors relating to group counseling involves the limited availability of support groups for young adults initially diagnosed with cancer in young adulthood (Kumar & Schapira, 2013). Of the study participants who looked for a young adult cancer support group, less than half were successful in finding one. Young adults may then turn to the Internet to find support, but even then they may not be successful in locating the type of support they need (Cohen, 2011). More local support groups for young adults diagnosed with cancer during young adulthood are needed to provide them with a uniquely powerful experience in which they are heard and understood by others like them, rather than by others much younger or older. Additionally, local counseling groups for young adults with cancer diagnosed during young adulthood that are led by counselors who understand their psychosocial concerns are needed. Taylor et al. (2013) reviewed four existentially based group counseling models for adult cancer survivors that counselors may consider based on their young adult clients’ needs: (a) cognitive-existential group therapy, (b) self-transcendence group therapy (c) meaning-centered group psychotherapy, and (d) supportive-expressive group therapy.
Participants’ lack of interest in the family counseling modality is an interesting result of this study. This result is supported by MacCormack et al.’s (2001) finding that many adults with cancer try to protect their friends and families by not sharing all of their emotional experiences with them. Rather than make general recommendations for clients who are young adults with cancer to participate in family counseling, counselors may want to make such recommendations on an individualized basis after thoroughly exploring clients’ psychosocial needs and preferences. Young adults with cancer are in a developmental period in which they are striving to live as independent adults (Arnett, 2000). A counselor suggesting that a young adult client with cancer participate in family counseling may be perceived as a suggestion that the client is unsuccessfully navigating this developmental period. For young adults who are interested in family counseling, a biopsychosocial approach guided by a medical family therapy framework (McDaniel, Hepworth, & Doherty, 1992) may be worth considering. This study can aid counselors in formulating hypotheses for what young adults with cancer may perceive as beneficial in different counseling modalities, as well as what types of counseling these clients would find helpful.
Implications for Future Research
Utilizing qualitative research methods may be especially helpful for future researchers (Kent et al., 2012) in continuing to explore young adults’ preferences for counseling topics in different counseling modalities. Researchers could incorporate the counseling topics included in this study in their interview questions to further explore these psychosocial areas, as well as to discover additional helpful counseling topics. Inquiring about the results of the counseling modality preferences in a qualitative study also could lead to further understanding about the contexts behind selecting one modality over another.
Additionally, research exploring how counseling can increase quality of life for young adults with cancer would be a significant contribution to the literature. Quinn, Gonçalves, Sehovic, Bowman, and Reed’s (2015) systematic review of the literature revealed a dearth of evidence-based approaches to enhance quality of life for adolescents and young adults with cancer. Because an experimental or quasi-experimental research design would be necessary to interpret whether counseling leads to an increase in quality of life, conducting such a research study would be complex and costly. But, a research study following up on these results to examine whether discussion of certain topics, participation in different counseling modalities, or particular counseling models can increase quality of life for young adults with cancer would greatly benefit the development of evidence-based psychosocial services for young adults with cancer.
Limitations
Mono-method bias was an inherent limitation to this study because of the sole use of self-report for data collection. Additional limitations include the use of a convenience sample, as well as lack of diversity among the participant characteristics of gender and race. Furthermore, the possibility exists that there are other counseling topics that young adults with cancer would find helpful to discuss in counseling that were not included on this study’s counseling needs assessment tool. Finally, if participants had never experienced one or more of the included counseling modalities, they may have been unsure about their perception of how helpful topics would be to discuss in those modalities or how they would rate their modality preferences.
Conclusion
The purpose of this study was to examine the perceived counseling needs of young adults with cancer. This study resulted in clarifying topics young adults with cancer would find helpful to discuss in individual counseling, group counseling, and family counseling. Young adults rated anxiety, finances, sad feelings, sexual and intimacy concerns, and stress management as most helpful for individual counseling; finding social support and getting information about one’s medical situation as most helpful for group counseling; and no topics as most helpful for family counseling. This study also found that young adults with cancer ranked individual counseling as their first choice for counseling modality, followed by group counseling and family counseling. Counselors and other mental health professionals can use these results as starting points for therapeutic conversations in various counseling modalities, creating treatment plans, establishing in-person groups, and developing evidence-based psychosocial programming and services for young adults with cancer in a variety of medical and supportive care settings.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Jessica Z. Taylor is an assistant professor at Central Methodist University. Susan Kashubeck-West is a professor and Associate Dean for Research at the University of Missouri–St. Louis. The authors would like to thank Hope for Young Adults with Cancer and the College of Education at the University of Missouri–St. Louis for their contributions of incentives for randomly selected study participants.Correspondence can be addressed to Jessica Taylor, Central Methodist University, 2458 Old Dorsett Road, Suite 200, Maryland Heights, MO 63043, jztaylor@centralmethodist.edu.
May 26, 2017 | Volume 7 - Issue 2
Yvette Saliba, Sejal Barden
Occupational stress is a top source of stress for over 65% of Americans due to extended hours in the workplace. Recent changes in health care have encouraged employers to build workplace wellness programs to improve physical and mental health for employees to mitigate the effects of occupational stress. Wellness programs focus on either disease management; treating chronic illnesses, such as hypertension and diabetes; lifestyle management; or preventing chronic illnesses through health promotion. This manuscript provides an overview of recent changes in health care and describes a conceptual framework, Steps to Better Health (S2BH), that counselors can use in workplace wellness programs. S2BH is an 8-week psychoeducational group based on the combination of motivational interviewing (MI) and the transtheoretical model of change (TTM).
Keywords: wellness, health care, workplace, stress, Steps to Better Health
Health and wellness are two concepts that have captured the attention of people throughout history. From Greek mythology to modern times, the idea of well-being has permeated society (Myers & Sweeney, 2007). Today, with the Patient Protection and Affordable Care Act (PPACA), health care is moving away from a disease treatment model and embracing a disease prevention model (PPACA, 2010). Although individuals typically do not invest in preventive health measures, many businesses and companies are eager to improve their health care programs for employees (Willis Towers Watson, 2017). These changes in health care are relevant to mental health providers, as a new focus on prevention has created opportunities for counselors to help effect lasting health changes among employees. Therefore, to fit into this paradigm shift, professional counseling should be strongly connected to prevention and wellness (Granello, 2013). This article discusses the changes in health care models, how those changes are creating spaces for mental health counselors to fill and implications for the counseling profession.
The Changing Landscape of Health Care
In 2015, the Kaiser Family Foundation released a report highlighting the rising cost of health care expenditures from 1960 to 2013. This report indicated that health care costs, which include total costs for hospital visits, physicians and clinics, as well as prescription medications, have risen from 27.4 billion dollars to over $2 trillion (Kaiser Family Foundation, 2015). Due in part to increases in the cost of health care and health insurance, the PPACA was passed into federal law in 2010. Mandates of the PPACA include: (a) preventing the denial of coverage for pre-existing conditions; (b) strengthening community health centers; (c) decreasing health disparities; (d) promoting integrated health systems; (e) connecting physician payments to the quality rather than the quantity of care provided; and (f) lowering long-term costs by providing free and more comprehensive preventive care (U.S. Department of Health and Human Services, Health Care, 2016). In a White House memo sent out during National Public Health Week in 2014, President Obama stated, “my administration is supporting efforts across our country to improve public health and shift the focus from sickness and disease to wellness and prevention” (Obama, 2014, p. 1).
This shift is clearly seen in the PPACA. Section 4001 of the PPACA, entitled “Modernizing Disease Prevention and Public Health Systems,” discusses ways in which health prevention should be carried out within the public sector (PPACA, 2010). This portion of the law includes a taskforce team that would: (a) evaluate wellness programs in 2013; (b) create the Prevention and Public Health Fund to distribute money to worksites establishing wellness programs; (c) further the education of health and wellness promotion; and (d) report on measures enacted that address lifestyle behavior modification (PPACA, 2010). Lifestyle behavior modification is defined as activities that include “smoking cessation, proper nutrition, appropriate exercise, mental health, behavioral health, substance use disorder, and domestic violence screenings” (PPACA, 2010, p. 422). In other words, initiatives from the federal government highlight the emphasis on prevention in both community and clinical health venues and extend this focus by supporting research into workplace wellness initiatives (Anderko et al., 2012). Though the PPACA encourages workplace wellness programs, many employers see the benefits to their employees even without federal regulations. In a recent survey, employers indicated they are still committed to better workplace wellness programs despite the unknown future of the PPACA (Willis Towers Watson, 2017). One primary motivator behind these programs is a reduction of employee stress through health promotion.
Health Promotion in the Workplace
According to the 2015 Bureau of Labor and Statistics report, Americans spent 8.8 hours a day at work or doing work-related activities (U.S. Department of Labor, 2016). Therefore, it can be estimated that Americans spend much of their lives in workplace settings, which can lead to occupation-related stress. In 2012, the American Psychological Association’s (APA) Stress in America Survey revealed that 65% of Americans reported work as a top source of stress (APA, 2016). Stress can affect a person’s emotional state, and it also can weaken the body’s ability to regulate itself after a stressful experience, which can eventually cause detrimental health consequences (Galla, O’Reilly, Kitil, Smalley, & Black, 2015). For example, the effects of chronic stress have been shown to lead to obesity and metabolic diseases (Razzoli & Bartolomucci, 2016). As a result, many individuals have resorted to maladaptive ways of coping with stress, highlighting the need for bringing stress management skills to the workplace (Galla et al., 2015). In addition, the World Health Organization has stated that health promotion in the workplace (promoting aspects of physical and emotional wellness) is beneficial in combating work-related stress (Jarman, Martin, Venn, Otahal, & Sanderson, 2015).
Finding ways to help employees manage their stress through health promotion in the workplace is typically conducted through workplace wellness programs, which include both lifestyle and disease management programs (Caloyeras, Hangsheng, Exum, Broderick, & Mattke, 2014; Kaspin, Gorman, & Miller, 2013; Mattke et al., 2013). Promoting positive health habits among employees maintains affordable health coverage and increases worker productivity (Anderko et al., 2012; Parkinson, Peele, Keyser, Liu, & Doyle, 2014; Shapiro & Moseley, 2013). Most workplace wellness programs focus on disease management, treating chronic illnesses such as diabetes and hypertension. Disease management programs also typically utilize health care professionals, such as nurses, to conduct face-to-face meetings or telephone consultations (Caloyeras et al., 2014). Conversely, lifestyle management programs prevent chronic illnesses by: (a) reducing stress; (b) lowering weight; (c) encouraging exercise; (d) promoting smoking cessation; and (e) fostering overall well-being (Caloyeras et al., 2014; Kaspin et al., 2013; Mattke et al., 2013).
Wellness Programs
Johnson & Johnson was an early pioneer in the creation and promotion of workplace wellness programs. In the 1970s, the company implemented a wellness program for employees called Live for Life (Ozminkowski et al., 2002). In 1993, this program was modified to integrate the following additional services: (a) employee health; (b) occupational medicine; (c) health promotion; (d) disability management; and (e) an employee assistance program. A modified program was rebranded with a new title: The Johnson & Johnson Health & Wellness Program (Ozminkowski et al., 2002). At the time of the program analysis, Johnson & Johnson employed approximately 40,000 people in the United States, 90% of whom participated in their wellness program. The program was evaluated by comparing outpatient doctor visits, hospital inpatient stays and mental health visits over the course of four years as compared to three years prior to the start of the wellness program. The worksite wellness program resulted in significant annual savings per employee/per year. On average, the study reported $45.17 savings for each outpatient visit, $119.67 per inpatient stays and $70.69 for mental health visits. In sum, Johnson & Johnson reported over $8 million in annual savings (Kaspin et al., 2013; Ozminkowski et al., 2002), creating a model wellness program that has been replicated in other organizations to varying degrees.
In contrast, PepsiCo offered a program in 2004 that did not produce similar results. Over 55,000 employees participated in a 3-year study, and it was determined that while costs were high in the initial year, it was the disease management portion of the program that lowered overall medical expenses by the third year (Liu et al., 2013). The disease management program was six to nine months in length and involved regular phone calls with a nurse for 15 to 25 minutes (Caloyeras et al., 2014). The program focused primarily on conditions such as asthma, coronary artery disease, congestive heart failure, hypertension and strokes (Caloyeras et al., 2014). Conversely, the lifestyle management portion of the program, which focused on weight management, nutrition management, fitness, stress management and smoking cessation, was described simply as involving a “series of telephonic calls with a wellness coach over a six-month period” (Caloyeras et al., 2014, p. 125). Training to become a wellness coach varies widely, ranging from a few days to 6 months. Training typically requires an associate degree and 18 weeks of classes conducted over the telephone or four full days of training in topics that include: (a) growth-promoting relationships; (b) expressing compassion; and (c) eliciting motivation to overcome ambivalence (Wellcoaches, 2016). The lack of sustainable changes in lifestyle wellness programs may be due to the variation and brevity of training for wellness coaches.
Hospitals have started employee wellness programs to lower employee health insurance costs, support mental health, and recruit and retain quality employees (Caloyeras et al., 2014; Hochart & Lang, 2011; Liu et al., 2013; Parkinson et al., 2014). Ironically, while the health care system is designed to help patients achieve good health, it often comes at the price of high stress levels and poor health for the employees (Chang, Hancock, Johnson, Daly, & Jackson, 2005; McClafferty & Brown, 2014; Smith, 2014). In fact, hospital employees tend to exhibit poorer health than other types of employees, which results in hospitals having the highest health care costs among employment sectors in the United States (Parkinson et al., 2014). As a result, some hospitals, such as the University of Pittsburgh Medical Center, are introducing the idea of employee wellness programs. In 2005, the University of Pittsburgh Medical Center utilized a prepackaged wellness program called MyHealth—a program that included both lifestyle and disease management components (Parkinson et al., 2014). Based on the number of requirements an employee met and activities he or she engaged in, the program provided credit that could be used to lower insurance deductibles (Parkinson et al., 2014). MyHealth consisted of online education materials, self-help tools, telephonic health coaching and support groups for lifestyle issues such as smoking cessation, depression, and emotional health and stress issues (Parkinson et al., 2014). Over a 5-year period, overall health care costs were lowered, but again, savings were attributed to the disease management portion of the program and not the lifestyle management portion (Caloyeras et al., 2014). Although there has been moderate success with wellness programs, the inclusion of counselors could make these programs more successful.
Need for Counselors in Wellness Programs
Changes in health care and increases in worksite wellness programs have created footholds for trained mental health professionals. As evidenced in the cases above, health care professionals, rather than mental health professionals, are facilitating lifestyle wellness programs. This is unfortunate, as professional counselors are trained in the skills of rapport building, demonstrating empathy and helping others achieve their goals. To build upon counselors’ inherent training and strengths may reduce the need for additional support and behavior change training. Utilizing counselors may result in stronger program implementation and cost savings for companies (Groeneveld, Proper, Absalah, van der Beek, and van Mechelen, 2011). Furthermore, although there have been some promising results and modest savings due to wellness programs, the variability in the content of wellness programs ranges widely. Therefore, it is proposed that having a program designed and led by counselors may have the potential to create larger savings for the lifestyle management portion of worksite wellness programs. With counselors utilizing their skills and coupling these techniques with aspects of motivational interviewing (MI) and the transtheoretical model of change (TTM), they could strengthen the lifestyle management portion of wellness programs and build on the foundation of wellness in counseling. To this end, we propose a psychoeducational lifestyle management conceptual framework that combines both MI and the TTM in an 8-week program, entitled Steps to Better Health (S2BH), which is described in the following section.
Components of S2BH
MI is an approach that helps individuals motivate themselves to pursue the changes that they seek. The founders of MI, Miller and Rollnick (2013), defined MI as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” (p. 12). More precisely, MI is about skillfully arranging conversations so that people talk themselves into changing (Miller & Rollnick, 2013). Further, MI has been positively correlated with stress reduction, medication adherence, diet change and exercise participation (Rollnick, Miller, & Butler, 2008). Miller and Rollnick (2013) asserted that people from all backgrounds could be trained to use the tools of MI; however, they emphasize that MI is not simply a collection of techniques (Miller & Rollnick, 2013). Rather, MI should be applied in a context that is characterized by client-counselor collaboration, client independence, and empowering clients to find and use their own resources for change (Young, Gutierrez, & Hagedorn, 2012). In addition to MI, the proposed wellness program integrates the TTM, an evidence-based model for change, and research on effective group work.
The TTM was developed by Prochaska and DiClemente (1982) to facilitate behavioral changes for individuals (Campbell, Eichhorn, Early, Caraccioli, & Greeley, 2012). The TTM consists of five stages of change individuals experience when changing behavior. The five stages are: (a) pre-contemplative (not thinking about change); (b) contemplative (thinking about change); (c) preparation (taking steps to begin change); (d) action (making the change); and (e) maintenance (creating a habit of new change; Shinitzky & Kub, 2001).
Prochaska et al. (2008) reviewed employee health promotion interventions, and results demonstrated that both MI and the TTM individually can lead to effective change. Participants (N = 1400) at a major medical university were assigned to three treatment groups: brief health risk intervention (BHRI) only (n = 433), online TTM-tailored treatment (n = 504), and an MI treatment group (n = 433; Prochaska et al., 2008). The results of the study showed that both the MI and TTM treatment groups had more individuals participating in the action stage for exercise and indicated better management of stress along with less health risk behaviors in 6 months than the BHRI only group (Prochaska et al., 2008). This study suggests that if both MI and TTM are effective separately, then combining them could lead to further success. Additionally, utilizing this combination within the framework of a psychoeducational group for a workplace would create efficiency.
Psychoeducational group work is ideal for a wellness program as it is a “hybrid of an academic course and counseling session” (Brown, 2011, p. 8). This format allows participants to feel as though they are attending a class, which can help them focus on learning and implementing a specific task without the potential stigma of therapy. For working professionals who may not feel the need to participate in traditional counseling, a psychoeducational group provides opportunity for discussions and activities in which individuals can practice various wellness techniques in a safe setting. Additionally, groups can be more cost-effective for businesses and organizations, as a number of individuals can simultaneously accomplish goals in a shared timeframe.
For many wellness programs, the results have been mixed due to expensive training and inadequate application of behavior change principles. For the lifestyle management portion of these wellness programs to be successful, a stronger framework would need to be implemented along with the use of professionally trained counselors. Therefore, a conceptual framework that counselors can consider adapting for a wellness lifestyle management program is proposed. The intention is to emphasize critical theoretical components while integrating practical ideas for counselors to build upon and adapt into their own lifestyle and health management programs.
S2BH
The proposed intervention of S2BH is an 8-week pyschoeducational group that incorporates aspects of both MI and the TTM. Each session consists of a short lesson about a concept related to change followed by a discussion that progressively moves each participant toward making the decision to change and successfully enacting those changes. Devoting 1 hour per week over the span of 8 weeks would yield overall balance and wellness among employees, leading to higher work performance and lower absenteeism (Vitality Institute, 2014). In addition to group sessions, the counselor should be available for optional one-on-one follow-up sessions, up to two times after the initial 8 weeks, ideally at the employer’s expense. These sessions would provide the opportunity for employees to address specific wellness concerns to help maintain changes. For demonstration purposes, below is a brief case example that demonstrates how S2BH could be utilized. In addition, Table 1 contains an overview of the program.
Case Illustration
Polly, a 46-year-old oncology nurse for 20 years, and Amelia, a 35-year-old oncology nurse for 9 years, work at Metro Hospital, a 2,000-bed acute care medical facility located in a busy downtown area. Both Polly and Amelia were frustrated about their workloads and felt burned out because of job stressors. They were both interested in joining the S2BH group, as it would give them more points in Metro’s HealthyYou! Campaign. These additional points could later be translated into monetary bonuses to encourage employee participation. After gaining permission from their nurse manager to be part of the S2BH group, both women joined seven other nurses from different floors once a week for an hour during their lunch break. Both Polly and Amelia completed physicals as a part of the campaign, and despite weight and blood pressure issues, neither of the physicals for both women showed severe health concerns.
During their first meeting, Polly shared feeling fatigued and believing that her lack of exercise played a part in that. Amelia stated that though she managed to walk once a week, she still felt lethargic both emotionally and physically, but was not sure why. During this first group, the counselor utilized one of the central principles of MI, which reflects listening skills to express empathy and genuine caring for the nurses. To close the group, everyone received the S2BH Wellness Primer Worksheet as homework.
Table 1
Suggested Curriculum for Steps to Better Health
|
Weekly Session
|
Session Details
|
Activities in Session
|
Homework Assigned
|
|
Week 1: Rapport Building and Therapeutic Alliance
|
Counselor will welcome the group and explain the weekly format, with emphasis on goal attainment. |
Participants will be encouraged to share work-related stressors and wellness goals. |
A worksheet will be provided for participants to outline wellness goals, steps needed to achieve goals and identification of stressors. |
|
Week 2:
Wellness Education
|
Participants will explore reasons for change and discuss the homework from the previous session. |
Participants will discuss potential pitfalls and necessary supports for successful change. |
Participants will identify what problems they encountered with their last change attempts. |
|
Week 3:
The Stages of Change
|
Counselor will give lesson on TTM, focusing on the stages of change. |
Participants will identify which stage of change they are in and work to develop stage-matched interventions. |
Participants will write down the advantages and disadvantages of achieving their wellness goal(s). |
|
Week 4:
Exploring Ambivalence
|
Counselor will lead a discussion on ambivalence (Miller & Rollnick, 2013; Shinitzky & Kub, 2001). |
Participants will discuss benefits and costs of not changing behavior. |
Each participant will identify one to two new habits as they move toward their wellness goal(s). |
|
Week 5:
Habit Formation
|
Counselor will discuss how participants can create new habits. |
Using homework, members will identify cues/routines/rewards for each new habit identified (Duhigg, 2012). |
Each participant will bring to the next session a brief update on their wellness goal(s). |
|
Week 6:
Reframing & Risk Assessments
|
Participants will discuss triggers and potential tactics to adhere to personal goals. |
Participants will identify and isolate potential triggers and solutions for the individual. |
Participants will identify stressors from work and life that could jeopardize wellness goal(s). |
|
Week 7:
Stress Busters
|
Participants will discuss stress and ways to enhance coping skills (e.g., emotion-based and action-based). |
Participants will use homework to identify appropriate coping skills for each stressor. |
Participants will use one of the identified coping skills over the next week. |
|
Week 8:
Wrap-Up
|
Participants will discuss how to stay motivated and engaged with wellness plans. |
Participants will discuss achievements followed by a termination activity. |
No homework assigned. |
Polly and Amelia came back to the second group with their S2BH Wellness Primer Worksheet results and were a little hesitant to begin discussing their results. After a few other members shared, Polly stated that the wellness primer made her more aware of her lack of exercise. Amelia then shared that this was the first time she had sat down and reflected on her health and well-being, and though she was not sure it was necessarily helpful, she was willing to try anything to stop feeling “blah.” Following the discussion on the wellness primer, group members worked on developing a wellness plan for the areas they wanted to improve. To close the session, the counselor discussed with the members ways to begin working on their goals in incremental steps and noted different ways they had started addressing those steps.
After learning about the stages of change from the TTM in the third session, Polly was animated about which stage she was on in relation to her goal of exercising more. She shared that she had been stuck on the contemplative stage of change for more years than she could count. She stated that she wanted to lose weight but could not seem to motivate herself to walk before her shift started.
Amelia stated that she wanted to eat better and classified herself as being in the pre-contemplative stage of change. She reported that she needed to eat better because she relied too often on caffeine and sugary foods to keep her going throughout the work day. Several of the group members expressed hope in knowing that they were not just “being lazy,” but were in a process of change. Amelia stated that just knowing that gave her a boost of energy.
After checking in during the fourth session and finding out where everyone was with their goals, the counselor led a discussion on the MI concept of ambivalence. Polly found this a little challenging, as she just wanted to list the pros and cons of her new health goals: exercising and eating better. Once she understood that she was to list both the benefits and costs of continuing her current behavior versus enacting her new health goal, she became more involved in the activity. As a result, Polly listed some pros of walking in the morning as being “it centers me as I release some of the frustration from the day before,” and “I use this time to organize my mind for the upcoming tasks for the day.” Amelia stated that some of her cons for not changing her behavior included “crashing hard around 4 p.m. in the afternoon” and “losing focus when working with patients.”
For the fifth session, a discussion centered around Duhigg’s (2012) book, The Power of Habit: Why We Do What We Do in Life and Business, and how members could apply the principle of cue, reward and routine to help them achieve their goals. Polly stated that she started putting her walking shoes out with her exercise clothes so that she could immediately see them when she woke up (cue). She would play her favorite podcast while walking (routine), and reward herself with a small low-calorie pastry for breakfast (reward). Amelia stated that she started to place almonds and other energy-boosting snacks at the nurses’ station so she could easily see them (cue), then would snack on those items while talking with colleagues (routine). As a result, she felt her energy lasting longer throughout the day (reward).
The nurses enjoyed reframing their previous “relapses” in the sixth session. Amelia reported that she was aware it was normal to move back and forth between the stages and that this knowledge alleviated concerns about failure. The group had a lively discussion about what triggers or pitfalls stood in their way and what places or things they should avoid as a result. For example, Polly stated that if she hit the “snooze button,” she would stay in bed and forgo her walk. Realizing this, she opted to place her alarm clock across the room so that she would have to get out of bed to turn off the alarm.
The seventh session on stressors became more emotional than anticipated as many of the nurses talked about their work and the unique stress they experience when taking care of ill and terminally ill patients. The group members talked about their thoughts and feelings and supported one another during this session. As a result, a spontaneous sharing of how nurses deal with the grief of losing patients occurred. Amelia shared that she had recently decided to join Team in Training for the Leukemia and Lymphoma Society and train for a half marathon in memory of one of her younger patients. She stated that letting the family know and beginning to raise money for research in this area was helping her to positively channel her grief. As a result of this discussion, several of the nurses stated that they left the group with hope, connectivity, and ideas for channeling their grief and stress.
The final session of the group focused on closure. Amelia shared that although she was initially dubious about the group, as a result of her sharing and the small changes she was making with her snacking, she was not feeling as “blah” anymore. Polly also shared that while she had not lost weight yet, she felt more motivated to continue walking and noticed that she felt more positive about walking.
Conclusion
Changes in health care have increased job opportunities in health care for counselors. The PPACA allows counselors the opportunity to expand their background of wellness while capitalizing on preventive health care initiatives (Barden, Conley, & Young, 2015; Granello & Witmer, 2013). With the interrelatedness between physical and mental health, counselors are ideally positioned to help clients achieve their wellness goals. Connections between physical activity and psychological well-being are well established, as are the potential benefits of improved coping with stress and adversity (Focht & Lewis, 2013). Because chronic stress has been shown to contribute to obesity and metabolic diseases (Razzoli & Bartolomucci, 2016), helping employees improve their coping skills can lead to adaptive ways of dealing with stress, which ultimately impacts chronic health conditions. To better manage occupational stress, counselors can fill the need for bringing stress management skills to the workplace (Galla et al., 2015).
In addition, wellness programs provide the ability for counselors to research their contributions to workplace wellness programs, thereby providing an opportunity to study counselor effectiveness. Research has shown that using health care professionals in disease management portions of wellness programs can lower costs. The focus of this manuscript has been to describe a framework for counselors to facilitate lifestyle management programs in corporate settings. Considerable sponsored research opportunities also are available, especially for worksite wellness programs targeted to underserved populations (U.S. Department of Health and Human Services Office of Minority Health, 2016).
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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Yvette Saliba, NCC, is a doctoral student at the University of Central Florida. Sejal Barden, NCC, is an Associate Professor at the University of Central Florida. Correspondence can be addressed to Yvette Saliba, 851 South State Road 434, Suite #1070-170, Altamonte Springs, FL 32714, ysaliba@knights.ucf.edu.
May 26, 2017 | Volume 7 - Issue 2
Laura Boyd Farmer
Counselors in school and community settings, counselor educators and counseling students (N = 453) participated in a study of self-perceived competence to serve lesbian, gay and bisexual (LGB) clients. Using the same large data set as Farmer, Welfare, and Burge (2013), the author examined different research questions focused on counselor religiosity and spirituality. Through multiple regression analysis, the following variables predicted LGB-affirmative counseling competence: counselors’ self-identified religiosity, spirituality, education, number of LGB clients counseled and LGB interpersonal contact. Spirituality had a positive relationship with competence, whereas religiosity was negatively related. Further exploration of the intersection of counselor religiosity and spirituality as it relates to LGB-affirmative counseling is warranted.
Keywords: LGB, lesbian, gay, bisexual, religiosity, spirituality, counselor competence
Lesbian-, gay- and bisexual- (LGB-) affirmative counseling encompasses a broad base of knowledge, awareness of attitudes, and skills that affirm and honor the lived experiences of sexual orientation diverse individuals, representing the ethical standard of care for all non-heterosexual clients (Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, 2012; Israel & Selvidge, 2003). Whitman and Bidell (2014) defined LGB-affirmative counseling as “a practice that adopts a science-based perspective of LGB sexual (or affectional) orientations as normal and healthy expressions of human development, sexuality, relationship, and love” (p. 164). In the last decade, the issue of providing competent, affirming care to clients who identify as lesbian, gay and bisexual (LGB) has risen to the forefront of professional dialogue for counselors. Two legal cases (Keeton v. Anderson-Wiley, 2011; Ward v. Polite, 2012) inspired meaningful discussion about the intersection of counselors’ religious and spiritual values and ethical counseling practices when working with sexual orientation diverse clients. The American Counseling Association (ACA) Code of Ethics (2014) mandates that counselors attend to value conflicts while working with clients to avoid the potentially harmful imposition of personal values (Kaplan, 2014). Still, some counselors are left with the task of integrating conflicting religious values with competent and affirming counseling practices with LGB clients (Herlihy, Hermann, & Greden, 2014; Robertson & Avent, 2016).
The political and social landscape surrounding LGB issues in the United States is in a state of flux. While the historic Obergefell v. Hodges (2015) decision established marriage equality for same-sex couples nationally, there have been conflicting influences on affirmative care. Conscience clause legislation, intended to protect mental health practitioners who deny services based on their own “sincerely held principles” (TN HB1840, 2016), has emerged in several states (e.g., Mississippi, Tennessee) as a response to the revised ACA Code of Ethics (2014). Conversion therapy or reparative therapy remains legal in 45 states despite being discredited and ethically opposed by all major mental health professions, including the ACA (American Psychological Association, 2017; Whitman, Glosoff, Kocet, & Tarvydas, 2013). Specifically, those ascribing to some religious affiliations assume a moral stance against non-heterosexual partnerships which is often rooted in narrow scriptural interpretations and traditional views on what constitutes a marriage (Lalich & McLaren, 2010). Smith and Okech (2016a) further probed professional discourse through their investigation of the Council for Accreditation of Counseling and Related Educational Programs (CACREP) accreditation status of counseling programs housed within religious institutions that disaffirm or disallow diverse sexual orientations, initiating an exchange of dialogue in the Journal of Counseling & Development (Sells & Hagedorn, 2016; Smith & Okech, 2016b). These authors highlighted incongruencies between the policies and philosophical statements of religiously affiliated institutions and the values espoused by the ACA Code of Ethics. In light of these prominent events and professional dialogue, counselors’ religious beliefs, as they relate to working with LGB clients, have received greater attention (Balkin, Watts, & Ali, 2014; Kaplan, 2014; Whitman & Bidell, 2014).
Spirituality, much like religion, is another complex facet of identity that contributes to counselor values. Although it has been established that counselors’ conservative religious beliefs may impact LGB-affirmative counseling (Balkin et al., 2014; Bidell, 2014), the impact of counselors’ spirituality is less understood. To date, no studies have investigated counselor religiosity and spirituality as potentially different aspects of identity that may relate to LGB-affirmative counselor competence, nor has the religious affiliation of counselors been explored. Therefore, the researcher sought to examine counselors’ self-identified religiosity and spirituality, as they relate to LGB-affirmative counseling competence.
The author conducted a large study of LGB-affirmative counselor competence that found school counselors perceived themselves as having lower competence to serve LGB clients than community-based counselors (Farmer, Welfare, & Burge, 2013). Using the same data set, the lead author has examined several new variables for the current study, including counselors’ self-identified religiosity, spirituality, education level, experience counseling LGB clients and LGB interpersonal contact. By examining these variables, new information is offered to the current professional discourse about the relevance of counselors’ religious and spiritual beliefs when counseling LGB clients.
Defining Religiosity and Spirituality
There are diverse opinions regarding definitions of religiosity and spirituality (Zinnbauer, Pargament, & Scott, 1999). The inconsistency in definitions creates a complex problem for researchers of religiosity and spirituality because it is difficult to know what meaning participants attribute to these terms (Zinnbauer et al., 1997). Although religiosity and spirituality have been shown to coincide for some, they are distinctly separate aspects of identity for others (Pargament, Sullivan, Balzer, Van Haitsma, & Raymark, 1995).
Religiosity has been broadly defined as the degree to which individuals subscribe to institution-alized beliefs or doctrines (Vaughan, 1991). Among basic methods of measuring religiosity is the indication of whether or not one identifies with a religious affiliation (Clark & Schellenberg, 2006). The frequency of service attendance and engagement in religious behaviors (e.g., prayer, scripture reading) are other methods of measuring religiosity (Lippman, Michelsen, & Roehlekepartain, 2005; Piedmont, 2001; Whitley, 2009). Self-ratings of religiosity are widely used that involve asking people to identify the importance of religion in their lives (Rainey & Trusty, 2007; Whitley, 2009). Chatters, Levin, and Taylor (1992) proposed a 3-dimensional model of religiosity that included organizational involvement (formal church attendance), nonorganizational involvement (informal activities such as prayer or scriptural study at home), and subjective religiosity (personal beliefs, attitudes and perceived importance of religion in one’s life). Aligning with these models, religiosity is understood in the current study as the degree of importance of religion in one’s life; frequency of service attendance and religious behavior (e.g., prayer, scriptural reading); and identification with a religious affiliation.
Alternately, spirituality is considered to be unique to individuals’ life experience and interpretation (Pargament, 2013). Spirituality is broadly described as an individual’s internal orientation toward a greater transcendent reality that joins “all things into a more unitive harmony” (Piedmont, 1999, p. 988). To develop a definition of spirituality, a “Summit of Spirituality” included 15 ACA members with representatives from a cross-section of ACA divisions who began the process of forming the counseling profession’s Spiritual Competencies (Association for Spiritual, Ethical, and Religious Values in Counseling, 2013). The summit resulted in the following description:
Spirituality is a capacity and tendency that is innate and unique to all persons. The spiritual tendency moves the individual toward knowledge, love, meaning, peace, hope, transcendence, connectedness, compassion, wellness, and wholeness. Spirituality includes one’s capacity for creativity, growth, and the development of a value system. (“Summit Results,” 1995, p. 30)
Pargament claimed “spirituality is the core function of religion” (2013, p. 271). In other words, people become involved in religion as a way to connect to the sacred and support their spirituality. Therefore, spirituality is a distinct motivation and human process that may exist apart from religion (Pargament, 2013). The current study is grounded in this understanding by examining counselors’ religious and spiritual identities as separate constructs (Pargament et al., 1995).
Counselors and Religiosity
Within studies of LGB-affirmative counselor competence, several factors have been shown to
negatively influence counselor competence, such as religiosity, church attendance, political conservatism, and heterosexism (Balkin, Schlosser, & Levitt, 2009; Bidell, 2014; Rainey & Trusty, 2007; Satcher & Schumacker, 2009). Scholars have postulated that the way scriptural references are interpreted may account for this negative influence, specifically interpretations that deem non-heterosexual behavior as immoral and socially deviant (Altemeyer, 2003; Poteat & Mereish, 2012; Whitley, 2009). Alternate views on scriptural references such as these include an understanding of cultural context, analysis of contradictory messages, and consideration of the human lens through which scripture was written (Dewey, Schlosser, Kinney, & Burkard, 2014; Friedman, 2001).
Bidell (2014) explored religious conservatism as it relates to counselor competence with LGB clients in a study of 228 counseling students, counselor educators and counseling supervisors in university settings. Religious conservatism was defined as religious fundamentalism, or “the belief that there is one set of religious teachings that clearly contain the . . . inerrant truth about humanity and deity” (Altemeyer & Hunsberger, 1992, p. 118). Religious conservatism was a significant negative predictor of LGB-affirmative counselor competence (β = -.532), whereas LGB interpersonal contact (β = .299) and LGB-specific training (β = .143) were positive predictors. In the analysis of the Sexual Orientation Counselor Competency Scale (SOCCS) subscales for attitudinal awareness, knowledge and skill, Bidell (2014) found that the attitudinal awareness and skill subscales were significantly related to religious conservatism, whereas knowledge was not. Implications suggest that counselors are influenced by conservative religious beliefs and attitudes toward LGB individuals.
More evidence has emerged concerning counselor religiosity and prejudice toward LGB individuals. Higher frequency of church attendance was a significant predictor of counselors’ negative attitudes toward LGB individuals (Satcher & Schumacker, 2009). Counselors who have more rigid and authoritarian orientations of religious identity exhibit more LGB prejudice (Balkin et al., 2009; Bidell, 2014; Sanabria, 2012). In light of these findings, more scholarly attention is focusing on ways to support “religiously conservative” counselors through the process of negotiating values conflicts (Choudhuri & Kraus, 2014; Fallon et al., 2013; Robertson & Avent, 2016; Whitman & Bidell, 2014).
Counselors and Spirituality
Ample research combines religion and spirituality, assuming these are synonymous aspects of identity or sources of values. However, some key studies have focused on the distinct contributions of spirituality in counselor development. Morrison and Borgen (2010) examined counselor empathy as it relates to and is influenced by counselor spirituality. Using the critical incident technique, 12 counselors with Christian beliefs identified 242 incidents where their spirituality helped their empathy toward clients and 25 incidents where their spirituality hindered empathy. Helping categories included counselors’ empathic connection with clients, the ability to draw on values of compassion and acceptance, and understanding other cultures. Hindering categories included experiences in which the client’s actions were contrary to the counselor’s belief system and having limited empathy due to counselor biases. Implications highlight the important role of spirituality in counselors’ felt empathy as well as the need for counselor training programs to create space for personal reflection on spiritual beliefs.
In a quantitative study, Saslow et al. (2013) sought to clarify meaning in the relationship between counselor spirituality and compassion while controlling for religiosity. Using an online sample from Amazon’s Mechanical Turk (n = 149), a nationally representative sample (n = 3,481), and a college undergraduate sample (n = 118), the authors measured global religiosity and spirituality, religious and spiritual practices, religious fundamentalism, self-transcendence, spiritual identity, questing orientation, global positive affect, dispositional compassion, awe, and love. Using principal components analysis, religiosity and spirituality loaded as distinct factors. Spirituality significantly predicted compassion after controlling for religiosity and positive affect. Alternately, religiosity was not a significant predictor of compassion while controlling for spirituality. Implications suggest compassion is central to spirituality.
Although researchers have focused on the relevance of client spirituality in the counseling process (Cashwell & Young, 2011; Parker, 2011), empirical studies investigating the impact of counselor spirituality are lacking. To date, no studies have examined the relationship between counselors’ self-identified spirituality, as differentiated from religiosity, and LGB-affirmative counselor competence. Therefore, the study was guided by the following research questions:
1) What are the relationships between counselors’ (a) self-identified religiosity, (b) self-identified spirituality, (c) education level, (d) counseling experience with LGB clients, (e) LGB interpersonal contact, and (f) LGB-affirmative counselor competence?
2) How do the variables of (a) self-identified religiosity, (b) self-identified spirituality,
(c) education level, (d) counseling experience with LGB clients, and (e) LGB interpersonal contact predict LGB-affirmative counselor competence?
3) Are there differences in counselors’ (a) self-identified religiosity, (b) self-identified spirituality, and (c) LGB-affirmative counselor competence among religious affiliation groups?
The author hypothesized that higher levels of self-identified religiosity would predict lower LGB-affirmative counselor competence, as established in Bidell’s previous study (2014). The author also hypothesized that all variables assessed would help explain the variance in counselors’ LGB-affirmative counselor competence.
Method
Procedure
The author used the same data set reported in Farmer et al. (2013) using different research questions and examining five new variables. The sample (N = 1,480) consisted of members of a state-level professional counseling association located in the Southeastern United States, including licensed professional counselors, professional school counselors, counselors-in-residence (post-master’s counselors working toward licensure), counseling graduate students and counselor educators. The researcher secured approval from the Institutional Review Board, obtained participant information from the state organization’s membership directory, and sent a recruitment e-mail inviting participation in the anonymous online survey using SurveyMonkey. Two reminder e-mails were sent at five and 10 days after initial contact. There were 556 respondents, yielding a response rate of 37.5%. The final sample included 453 participants following data-cleaning procedures and eliminating those respondents whose practice setting could not be verified.
Participants
Of the 453 participants, 212 (46.8%) described their primary practice setting as school, 110 (24.3%) described their practice setting as community, 93 (20.5%) were described as counseling graduate students, and 38 (8.4%) were counselor educators. Participants’ ages ranged from 22 to 75 years, with an average age of 41.5 years (SD = 13.5). Seventy-three participants (16.1%) identified as men and 379 (83.7%) identified as women (one participant omitted this item). With regard to race, 376 participants (83.0%) identified as Caucasian, 55 (12.1%) as African American, eight (1.8%) as Hispanic, eight (1.8%)
as multiracial or other, three (0.7%) as American Indian, one (0.2%) as Asian, and one (0.2%) as Hawaiian or Pacific Islander (one participant omitted this item). Regarding sexual orientation, 425 participants (93.8%) identified as heterosexual, seven (1.5%) as lesbian, five (1.1%) as gay, five (1.1%) as bisexual, one (0.2%) as questioning, and four (0.9%) as other (six participants omitted this item). Participants were also asked to identify their religious affiliation (e.g., Protestant Christian, Catholic, Other Religious Affiliation, No Religious Affiliation). Table 1 displays descriptive data on religious affiliation and SOCCS scores.
Instruments
Two instruments and an information questionnaire were used to collect data. The SOCCS (Bidell, 2005) was used to assess LGB-affirmative counselor competence. The Marlowe-Crowne Social Desirability Scale—Short Form C (MC-C; Reynolds, 1982) assessed the authenticity of participant responses. An information questionnaire gathered demographic and personal background information, including items for counselors to indicate self-identified religiosity and spirituality.
Sexual Orientation Counselor Competency Scale. This instrument measures participants’ self-perceptions of LGB-affirmative counseling competence including attitudes, knowledge and skills (Bidell, 2005). The SOCCS contains 29 items that are rated on a 1–7 scale (1 = not at all true, 7 = totally true). Ten items measure attitudes (e.g., “The lifestyle of an LGB client is unnatural or immoral”), eight items measure knowledge (e.g., “There are different psychological/social issues impacting gay men versus lesbian women”), and 11 items measure skill (e.g., “I feel competent to assess the mental health needs of a person who is LGB in a therapeutic setting”). Convergent validity was established for each of the three subscales (attitudinal awareness, knowledge and skill) using existing measures of LGB bias, multicultural knowledge and basic counseling skills, respectively. Bidell (2005) reported strong internal consistency for the SOCCS: .90 for the overall score, .76 for Knowledge, .88 for Attitudes, and .91 for Skill. In this sample (N = 453), the coefficient alphas are reasonably comparable: .87 for the overall score, .72 for Knowledge, .87 for Attitudes, and .87 for Skill.
Table 1
Mean Values for SOCCS Total and Subscales by Religious Affiliation
| Group |
N |
M |
Attitudes |
Knowledge |
Skill |
| Protestant Christian |
237 |
4.51 |
6.17 |
4.04 |
3.34 |
| Assembly of God |
1 |
|
|
|
|
| Baptist |
36 |
|
|
|
|
| Brethren |
4 |
|
|
|
|
| Christian |
82 |
|
|
|
|
| Church of Christ |
1 |
|
|
|
|
| Disciples of Christ |
4 |
|
|
|
|
| Episcopal |
17 |
|
|
|
|
| Lutheran |
9 |
|
|
|
|
| Mennonite |
3 |
|
|
|
|
| Methodist |
48 |
|
|
|
|
| Morman |
2 |
|
|
|
|
| Non-Denominational |
12 |
|
|
|
|
| Pentecostal |
1 |
|
|
|
|
| Presbyterian |
17 |
|
|
|
|
| Catholic |
88 |
4.70 |
6.51 |
4.22 |
3.41 |
| Roman Catholic |
87 |
|
|
|
|
| Byzantine Catholic |
1 |
|
|
|
|
| Other Religious Affiliation |
29 |
5.25 |
6.85 |
4.69 |
4.19 |
| Buddhist |
4 |
|
|
|
|
| Jewish |
9 |
|
|
|
|
| Native American |
1 |
|
|
|
|
| Religious Soc. Friends |
5 |
|
|
|
|
| Taoist |
1 |
|
|
|
|
| Unitarian |
9 |
|
|
|
|
| No Religious Affiliation |
99 |
4.95 |
6.74 |
4.43 |
3.70 |
| None identified |
93 |
|
|
|
|
| Agnostic |
5 |
|
|
|
|
| Atheist |
1 |
|
|
|
|
|
|
|
|
|
|
| Total |
453 |
4.69 |
6.41 |
4.20 |
3.49 |
Marlowe-Crowne Social Desirability Scale—Short Form C (MC-C). This 13-item self-report instrument measures participants’ tendency to answer questions to portray oneself in favorable ways (e.g., “I am always willing to admit when I make a mistake.”). The items are answered as true or false and then summed for a total score. Higher scores on the MC-C reflect higher levels of social desirability. In this sample, internal consistency of the 13 items in the MC-C was .77 (N = 453), which is comparable to previous tests of the internal consistency of the MC-C (Reynolds, 1982).
Information questionnaire. An information questionnaire was developed to gather basic demographic and background information. In addition to demographic variables of age, race, ethnicity, sexual orientation and gender identity, five additional variables were evaluated: (a) self-identified religiosity, (b) self-identified spirituality, (c) education level, (d) counseling experience with LGB clients (the number of LGB clients worked with), and (e) LGB interpersonal contact (the number of friends and relatives who identify as LGB).
A brief, 4-item measure of self-identified religiosity captured the importance of religion in participants’ lives based on previous studies (Rainey & Trusty, 2007; Whitley, 2009) and census methods of measuring religiosity (Clark & Schellenberg, 2006; Lippman et al., 2005). Participants were asked to rate the importance of religion in their lives (0 = not at all, 1 = somewhat, 2 = important, 3 = very important), service attendance (0 = never, 1 = few times a year, 2 = few times a month, 3 = once a week or more), personal practices (0–7 scale = number of days per week spent engaging in religious behavior such as praying, reading scripture), and religious affiliation (open-ended; 0 = no identified religious affiliation, 1 = identified religious affiliation). Item scores were transformed into z-scores and then summed, where higher scores indicate higher levels of religiosity. In this sample, internal consistency of the four items in the religiosity measure was .82.
A brief, 5-item measure of self-identified spirituality was used to assess distinct aspects of spirituality from religiosity. A modified version of the Spiritual Transcendence Index (STI) was used, where spiritual transcendence refers to “a subjective experience of the sacred that affects one’s self-perception, feelings, goals, and ability to transcend difficulties” (Seidlitz et al., 2002, p. 441). The STI demonstrated high consistency and validity across several samples in exploratory studies, including adaptations of the STI such as those employed in this study (Good, Willoughby, & Busseri, 2011; Kim & Seidlitz, 2002; Seidlitz et al., 2002). The modified version of the STI used four items that did not include the term “God.” In this study, it was important that the concept of spirituality not be limited to only theists. For the four items, participants were asked to rate their experience of the following on a 1–6 scale (1 = strongly disagree to 6 = strongly agree): “My spirituality gives me a feeling of fulfillment,” “Even when I experience problems, I can find a spiritual peace within,” “Maintaining my spirituality is a priority for me” and “My spirituality helps me to understand my life’s purpose.” Finally, one question was posed in a similar format to Nelson, Rosenfeld, Breitbart, and Galietta (2002) asking respondents to rate the importance of spirituality in their lives (0 = not at all, 1 = somewhat, 2 = important, 3 = very important), which mirrors the wording of the parallel item in the religiosity measure. Item scores were transformed into z-scores and then summed, where higher scores reflect higher levels of self-identified spirituality. In this sample, internal consistency of the five items in the spirituality measure was .96 (N = 453), reflecting strong scale reliability. Validity of modified versions of the STI also has been established (Good et al., 2011; Kim & Seidlitz, 2002).
Data Cleaning
To ensure quality and rigor, participants who answered less than 70% of the items on the SOCCS or MC-C were eliminated from the sample, based on the methodology of Henke, Carlson, and McGeorge (2009) and Rock, Carlson, and McGeorge (2010). Of the 556 initial respondents, 61 did not complete the required 70% minimum (20 of 29 items) on the SOCCS. The religiosity and spirituality measures included only four and five items, respectively; therefore, if even one item was omitted from either measure, those participants were eliminated from the sample (n = 15). Finally, 27 respondents did not indicate their primary practice setting and were eliminated from the sample because the researcher could not confirm that they were a counselor.
Further data cleaning was necessary for participants who completed more than 70–100% of the SOCCS or MC-C. For those who omitted one to eight items (n = 89) on the SOCCS or one to three items on the MC-C (n = 8), mean imputation accounted for missing items (Montiel-Overall, 2006). Of those 89 cases that were modified using mean imputation for the SOCCS, 61 participants had omitted only one item and 12 omitted only two items. The remaining 16 participants omitted three to seven items.
Results
The purpose of the study was to investigate the following factors as they relate to and predict LGB-affirmative counselor competence: counselor self-identified religiosity, spirituality, education level, counseling experience with LGB clients and LGB interpersonal contact. To answer the research questions, correlational analysis, multiple regression and analysis of variance (ANOVA) were conducted. The researcher completed post-hoc power analyses using G*power at the .05 level of statistical significance. The effect size and achieved power is reported for each analysis.
For Research Question 1, a correlational matrix presents the relationships among all variables in Table 2. There was a significant, although weak, correlation between LGB-affirmative counselor competence and social desirability (r2 = -.15, p < .01). This suggests that the SOCCS results were not significantly inflated by social desirability.
Table 2
Correlation Matrix for Main Study Variables
| Variable |
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
9
|
10
|
| 1. MC-C |
–
|
-.15**
|
-.06
|
-.28**
|
-.05
|
.08
|
.10*
|
-.03
|
-.06
|
-.01
|
| 2. SOCCS Total |
|
–
|
.57**
|
.62**
|
.88**
|
-.30**
|
-.04
|
.31**
|
.35**
|
.24**
|
| 3. Attitudes |
|
|
–
|
.12*
|
.27**
|
-.47**
|
-.31**
|
.08
|
.11*
|
.18**
|
| 4. Knowledge |
|
|
|
–
|
.35**
|
-.17**
|
.04
|
.16**
|
.05
|
.17**
|
| 5. Skill |
|
|
|
|
–
|
-.11*
|
.08
|
.34**
|
.45**
|
.18**
|
| 6. Religiosity |
|
|
|
|
|
–
|
.60**
|
-.01
|
.03
|
-.12*
|
| 7. Spirituality |
|
|
|
|
|
|
–
|
.07
|
.11*
|
-.04
|
| 8. Education |
|
|
|
|
|
|
|
–
|
.22**
|
.06
|
| 9. LGB clients |
|
|
|
|
|
|
|
|
–
|
.10
|
| 10. LGB interpersonal |
|
|
|
|
|
|
|
|
|
–
|
Note. MC-C = Marlow Crowne Social Desirability Scale – Short Form C; SOCCS Total = Sexual Orientation Counselor Competency Scale Total score; Attitudes = SOCCS Attitudinal Awareness Subscale; Knowledge = SOCCS Knowledge Subscale; Skill = SOCCS Skill Subscale; Religiosity = self-identified religiosity measure; Spirituality = self-identified spirituality measure; Education = highest degree earned in counseling; LGB clients = number of LGB clients counseled; LGB interpersonal = number of LGB friends/relatives
Among initial findings, religiosity had a significant negative relationship with SOCCS total scores (r = -.30, p < .01) including significant negative relationships for all three of the SOCCS subscales (Attitudes, r = -.47; Knowledge, r = -.17; and Skill, r = -.11). Spirituality was not related to SOCCS total scores (r = -.04, p > .05), yet spirituality was strongly correlated with religiosity (r = .60, p < .01).
For Research Question 2, multiple regression analysis was conducted to determine predictors of LGB-affirmative counselor competence. The criterion variable was total score on the SOCCS and the predictors were (a) religiosity, (b) spirituality, (c) education level, (d) counseling experience with LGB clients, and (e) LGB interpersonal contact. The results of the regression indicated that these five predictors explained 31% of variance in SOCCS scores (R2 = .31, F(5, 391) = 35.31, p < .01). All five variables significantly predicted SOCCS scores: religiosity (β = -.40, p < .01), spirituality (β = .13, p < .05), education (β = .23, p < .01), number of LGB clients worked with (β = .28, p < .01), and LGB interpersonal contact (β = .13, p < .01). Notably, there was a negative β value for religiosity, indicating an inverse relationship with SOCCS scores compared to a positive β value for spirituality and SOCCS scores. With a medium effect size of .45 (Cohen, 1992), achieved power for the multiple regression was 1.00.
For Research Question 3, ANOVA was used to examine differences in three variables (religiosity, spirituality, and LGB-affirmative counselor competence) across the following religious affiliation groups: Protestant Christian, Catholic, Other Religious Affiliation, and No Religious Affiliation. Table 1 displays the affiliations included in each group.
Religious affiliation and religiosity. A one-way, between-subjects ANOVA compared the effect of religious affiliation on religiosity in four groups: Protestant Christian (n = 237), Catholic (n = 88), Other Religious Affiliation (n = 29), and No Religious Affiliation (n = 99). There was a significant effect of religious affiliation on religiosity [F(3, 449) = 156.69, p = .000]. Post-hoc comparisons using Tukey HSD indicated that the mean score for No Religious Affiliation (M = -4.12, SD = 2.30) was significantly lower than Protestant Christian (M = 1.61, SD = 2.20), Catholic (M = .45, SD = 2.39), and Other Religious Affiliation (M = -.73, SD = 2.11). In addition, Protestant Christian (M = 1.61, SD = 2.20) was significantly higher in religiosity than Catholic (M = .45, SD = 2.39) and Other Religious Affiliation (M = -.73, SD = 2.11) groups. With a large effect size of 1.04 (Cohen, 1992), achieved power for the ANOVA was 1.00.
Religious affiliation and spirituality. A one-way, between-subjects ANOVA compared the effect of religious affiliation on spirituality in four conditions: Protestant Christian, Catholic, Other Religious Affiliation, and No Religious Affiliation. There was a significant effect of religious affiliation on spirituality [F(3, 449) = 16.17, p = .000]. Post-hoc comparisons using Tukey HSD indicated that the mean score for Protestant Christian (M = 1.22, SD = 3.45) was significantly higher than Catholic (M = -.69, SD = 4.29) and No Religious Affiliation (M = -2.31, SD = 6.06) groups. With a medium effect size of .31 (Cohen, 1992), achieved power for the ANOVA was 0.99.
Religious affiliation and LGB-affirmative counseling competence. A one-way, between-subjects ANOVA compared the effect of religious affiliation on LGB-affirmative counseling competence in four groups: Protestant Christian, Catholic, Other Religious Affiliation, and No Religious Affiliation. There was a significant effect of religious affiliation on LGB-affirmative counseling competence [F(3, 449) = 12.98, p = .000]. Post-hoc comparisons using Tukey HSD indicated that the mean score for Protestant Christian (M = 4.51, SD = .77) was significantly lower than No Religious Affiliation (M = 4.95, SD = .78). Furthermore, the mean score for Other Religious Affiliation (M = 5.25, SD = .78) was significantly higher than Protestant Christian (M = 4.51, SD = .77) and Catholic (M = 4.70, SD = .75). Using G*Power, post-hoc power analysis was conducted. With a small effect size of .23 (Cohen, 1992), achieved power for the ANOVA was .98.
Discussion
Results of this study indicate that counselor religiosity and spirituality are each significant predictors of LGB-affirmative counselor competence. Counselor religiosity had a negative relationship with LGB-affirmative counselor competence (β = -.40, p < .01), whereas counselor spirituality had a positive relationship with LGB-affirmative counselor competence (β = .13, p < .01). Although counselors’ self-identified spirituality and religiosity were correlated (r = .60, p < .01), the opposing directions of the relationship between counselor religiosity and spirituality with LGB-affirmative counseling competence is intriguing.
The current study examined counselors’ self-identified religiosity as the degree of involvement in their religions, without knowledge of the specific nature of religious beliefs. It is possible that the negative relationship found between religiosity and LGB-affirmative competence is associated with conservative or fundamentalist beliefs, as found in Bidell’s (2014) study. Nonetheless, the significance of counselors’ self-identified spirituality as a positive predictor of LGB-affirmative counseling competence is new and useful information. Spirituality has been linked to empathy (Morrison & Borgen, 2010) and compassion for others (Saslow et al., 2013), which also may be factors related to LGB-affirmative counseling competence. Further empirical investigation of these variables is necessary to draw further conclusions.
The current study substantiates previous findings that education, the number of LGB clients worked with, and LGB interpersonal contact are positive predictors of LGB-affirmative counselor competence (Bidell, 2014). Reviewing the correlations of the SOCCS subscales (Table 2), education was most strongly related to skill (r2 = .34, p < .01), weakly related to knowledge (r2 = .16, p < .01) and unrelated to attitudes (r2 = .08, p > .05). It may be surmised that more education may move the marker on LGB-affirmative knowledge and skill, but is less related to affirming attitudes. Counseling experience with LGB clients was moderately correlated to skill (r2 = .45, p < .01), weakly related to attitudes (r2 = .11, p < .05), and unrelated to knowledge (r2 = .05, p > .05). Considering that counselors perceive themselves to have affirming attitudes toward LGB clients but have lower knowledge and skill (Bidell, 2012, 2014; Farmer et al., 2013; Graham, Carney, & Kluck, 2012), obtaining more counseling experience with LGB clients may be essential to strengthen self-perceived skill.
Finally, the ANOVA results suggest differences between religious affiliation groups in this study. Counselors in the “Protestant Christian” group were significantly lower in LGB-affirmative competence than counselors with “No Religious Affiliation.” Likewise, counselors in the “Other Religious Affiliation” group were significantly higher in LGB-affirmative competence than the “Protestant Christian” and “Catholic” groups. Furthermore, there were no significant differences in spirituality between “Protestant Christian” and “Catholic” groups, yet there was a significant difference in the religiosity of these two groups. These results suggest that the two groups shared similarly high spirituality but did not share the same religiosity as it was measured in this study.
If religion is theorized as a function of spirituality (Pargament, 2013), then results of this study seem to support that counselor spirituality may facilitate LGB-affirmative dispositions. It is possible that only certain religious beliefs interfere with this relationship to negatively affect LGB-affirmative counseling. As further support, there was a significant difference between “Protestant Christian,” “Catholic,” and “Other Religious Affiliation” groups with regard to LGB-affirmative competence. No firm conclusions can be drawn, but these results provide fodder for those in the field of professional counseling to discuss and consider.
Limitations
When self-report measures are used in a study of multicultural competence, there is a risk that participants may respond more favorably due to the influence of social desirability. Furthermore, self-perceived LGB-affirmative competence was measured using the SOCCS, which may not reflect actual competence with LGB clients. There is a chance of sampling bias due to the possibility that those who had greater interest in the topic of the study self-selected to participate. Finally, the nature of participants’ religious beliefs was not examined; therefore, there may be wide variability in beliefs within each of the religious affiliation groups examined (e.g., Protestant Christian, Catholic, Other Religious Affiliation).
Implications
Results of this study suggest that religiosity and spirituality both predict LGB-affirmative counselor competence, but in different ways. Spirituality was a direct, positive predictor of LGB-affirmative counselor competence, while religiosity was a negative predictor. Results align with previous findings that suggest for highly religious counselors, LGB-affirmative counselor competence is most impacted by attitudes as opposed to the development of knowledge and skill (Bidell, 2014).
Considerations for Counselors
Religiosity and spirituality may each provide structure or ideological substance needed to develop one’s sense of values concerning counseling LGB clients. Whereas religion may derive ideological substance from certain doctrines, scriptures or teachings, spirituality is likely to derive ideological substance from more intuitive or nontangible forms of meaning-making that drive human connection (Zinnbauer et al., 1999). Considering this, it seems possible that counselors who identify as both highly religious and spiritual could experience inner conflict related to integrating LGB-affirmative values if their religious doctrines or teachings have been interpreted in such a way as to condemn same-sex relationships (Altemeyer, 2003; Poteat & Mereish, 2012; Whitley, 2009). In this case, such counselors may be trying to negotiate two important ways of knowing and making meaning about the world: one derived from religious teachings and the other from intuitive or heart-centered means. Thus, if a counselor is experiencing a values conflict between their personal religious beliefs and LGB-affirmative practices supported by the ACA Code of Ethics (2014), it may be mutually beneficial to explore the common thread of spirituality to forge empathic connection.
Practical suggestions for counselors include self-reflection on spiritual and religious values and beliefs, peer consultation, supervision, and seeking consult from a variety of religious and spiritual leaders. It may be helpful for counselors to consider values from their religious affiliations that are congruent with LGB-affirmation to encourage integration. Through these activities, counselors may develop a deeper understanding of the complex ideas, beliefs and values that are important to their religious and spiritual selves.
Counselor Educators and Supervisors
Whitman and Bidell (2014) offered recommendations to counselor educators and supervisors for training LGB-affirmative counselors, such as conducting a thorough and honest appraisal of the program’s level of LGB-affirmative counselor education integration, providing clear informed consent to potential students regarding the LGB-affirmative approach infused into the curriculum, and encouraging student exploration of how personal values may affect worldview. As a pedagogical technique for encouraging self-exploration, Fischer and DeBord (2007) recommended evoking conversation with students when conflict is perceived between a student’s religious values and professional obligations. Normalizing these experiences of struggle for students may be helpful, particularly for those whose religious beliefs are salient to their cultural identities (Robertson & Avent, 2016; Scott, Sheperis, Simmons, Rush-Wilson, & Milo, 2016). In these situations, students may be encouraged to explore and question the assumptions and beliefs that are involved in the perceived conflict with professional and ethical values (Whitman & Bidell, 2014). Kocet and Herlihy (2014) also proposed an ethical decision-making model and approach to managing values conflicts for counselors.
Finally, LGB interpersonal contact had a positive impact on LGB-affirmative counseling competence in this study. Learning activities designed to increase contact with LGB individuals, such as panel discussions or immersion experiences (e.g., Pride Festival attendance) may encourage students to consider personal views more deeply and develop new ways of understanding themselves and the world around them. Considering that counselors’ self-perceived skill was correlated to the amount of counseling experience with LGB clients, it may be useful for counselor educators to find ways to diversify client demographics for practicum and internship students, including affectional orientation, to strengthen LGB-affirmative counseling skills.
Future Research
Although this study captured self-identified religiosity and spirituality through brief measures, a more robust and multidimensional measure of religiosity and spirituality is recommended for future studies. Further investigation of the intersection of counselor religiosity and spirituality is recommended because of the strong correlation between these variables, and might be best explored through qualitative studies. The specific nature of religious beliefs held by highly religious counselors was not verified and may be explored. Future researchers should also explore factors, such as developing empathy for clients, that potentially mediate the effect of prejudicial religious beliefs on LGB-affirmative counselor competence.
Conclusion
In this study, counselor spirituality was a direct predictor of LGB-affirmative counselor competence, evoking the question: What might contribute to a counselor’s sense of spirituality, apart from religious doctrine or dogma that might otherwise compromise an affirming disposition toward LGB clients? Spirituality has been described as an innate capacity that moves us toward “knowledge, love, meaning, peace, hope, transcendence, connectedness, compassion, wellness and wholeness” and contributes to our value system (“Summit Results,” 1995, p. 30). Perhaps the spiritual experience of compassion and the desire for connection provides a broader understanding and embodiment of LGB-affirmative counseling practices at the human level. After all, it stands to reason that multicultural counseling competence across diverse populations stems from an inward striving for unconditional acceptance and validation of the unique experiences of others. To nurture these connections in ourselves and in our work is perhaps one of the greatest gratifications of being a professional counselor.
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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May 26, 2017 | Volume 7 - Issue 2
Kimberly Ernst, Gerta Bardhoshi, Richard P. Lanthier
This study explored the relationships between demographic variables, self-efficacy and attachment style with a range of performed and preferred school counseling activities in a national sample of elementary school counselors (N = 515). Demographic variables, such as school counselor experience and American School Counselor Association (ASCA) National Model training and use, were positively related to performing intervention activities that align with the ASCA National Model. Results of hierarchical regression analyses supported that self-efficacy beliefs also predicted levels of both actual and preferred service delivery of intervention activities. Interestingly, self-efficacy beliefs also predicted higher levels of performing “other” non-counseling activities that are considered to be outside of the school counselor role. An insecure attachment style characterized by high anxiety predicted a lower preference for intervention activities and also predicted the discrepancy between actual and preferred “other” non-counseling activities, revealing a higher preference for performing them.
Keywords: school counselor, ASCA National Model, self-efficacy, attachment style, service delivery
Professional school counselors are important contributors to education and serve an essential role in the academic, personal, social and career development of all students (American School Counselor Association [ASCA], 2012). Over the past decade, school counselors have been increasingly called upon to embrace data-driven, evidence-based standards of practice (ASCA, 2012; Erford, 2016) that bolster the achievement of all students (Shillingford & Lambie, 2010). Comprehensive developmental school counseling programs that are consistent with the ASCA National Model are currently considered best practice (ASCA, 2012) and identified as an effective means of delivering services to all students (Burnham & Jackson, 2000; Carey & Dimmitt, 2012; Gysbers & Henderson, 2012).
Data from school counseling research indicate that comprehensive developmental school counseling programs make a positive difference in student outcomes (Carey & Dimmitt, 2012; Scarborough & Luke, 2008). These programs are shown to impact overall student development positively, including academic, career and emotional development, as well as academic achievement (Fitch & Marshall, 2004; Lapan, Gysbers, & Petroski, 2001; Sink & Stroh, 2003). Furthermore, a range of individual school counselor activities and interventions is associated with positive changes in a number of important student outcomes, including academic performance, school attendance, classroom behavior and self-esteem (Whiston, Tai, Rahardja, & Eder, 2011).
However, studies examining actual school counselor practice indicate that school counselors spend a significant amount of time on activities that are not reflective of ASCA best practices, including clerical, administrative and fair share duties that take them away from performing essential school counseling activities (Bardhoshi, Schweinle, & Duncan, 2014; Burnham & Jackson, 2000; Foster, Young, & Hermann, 2005; Scarborough & Luke, 2008). A factor impeding school counselors’ ability to perform activities that align with best practices includes being burdened with time-consuming tasks that are outside their scope of practice (Bardhoshi et al., 2014). This may stem from either the historically ambiguous school counselor role (Gysbers & Henderson, 2012) or from competing demands from numerous stakeholders who may not fully understand the components of an effective school counseling program (Bemak & Chung, 2008). Indeed, school counselors report not spending adequate time engaged in the professional activities that they prefer (Scarborough, 2005; Scarborough & Luke, 2008), even though these preferences are consistent with best practice recommendations (Scarborough & Culbreth, 2008). Therefore, for many school counselors, performing within their professional role and sticking to best practice recommendations regarding their service delivery can be challenging and stressful (McCarthy, Kerne, Calfa, Lambert, & Guzmán, 2010).
Given that school counseling program implementation and interventions that align with ASCA are associated with positive outcomes for students in a variety of domains, and that tension exists between the actual and preferred practice of school counselors, the question now becomes: What factors contribute to effective school counseling service delivery? Studies indicate a positive relationship between years of experience and school counselor practice (Scarborough & Culbreth, 2008; Sink & Yillik-Downer, 2001), as it may take several years of experience to implement the breadth and complexity of interventions in a programmatic manner. Research outside the field of school counseling also has expanded beyond demographic variables to indicate that a number of individual characteristics, such as attachment style (Dozier, Lomax Tyrrell, & Lee, 2001; Hazan & Shaver, 1987), emotional stability, locus of control, self-esteem (Judge & Bono, 2001) and self-efficacy (Judge & Bono, 2001; Larson & Daniels, 1998), are related to an individual’s work performance.
To understand the underlying mechanisms that affect school counselor work performance, studies have explored potential organizational (e.g., school climate, perceived administration support), structural (e.g., training, supervision), and personal variables (e.g., experience, self-efficacy) related to counselor practice (Scarborough & Luke, 2008). Two school counselor interpersonal variables are of special focus in this study: self-efficacy and attachment. Individuals with higher levels of self-efficacy set higher goals for themselves and show higher levels of commitment, motivation, resilience and perseverance in achieving set goals (Bodenhorn & Skaggs, 2005), making the examination of school counselor self-efficacy important in investigating effective service delivery. On the other hand, attachment theory highlights the process by which early childhood development influences an individual’s capacity to relate to others and regulate emotion. Many lines of theoretical and empirical research in education and psychology have examined how attachment characteristics influence adult functioning, supporting the introduction of school counselor attachment style as a factor relating to work performance (Desivilya, Sabag, & Ashton, 2006; Hazan & Shaver, 1987; Kennedy & Kennedy, 2004; Marotta, 2002). School counselor self-efficacy and attachment characteristics are personal attributes conceptualized to contribute to the ability of school counselors to perform intervention activities that align with ASCA recommendations and positively impact student development and achievement.
Self-Efficacy
Self-efficacy involves beliefs about one’s own capability to successfully perform given tasks to accomplish specific goals (Lent & Hackett, 1987). As individuals confront important problems and tasks, they choose actions based on their beliefs of personal efficacy (Bandura, 1996). Self-efficacy may be a critical factor in school counselor work performance. Two meta-analytic studies of empirical research examining self-efficacy have shown that for a variety of occupations, there is a positive relationship between self-efficacy and work performance (Larson & Daniels, 1998; Stajkovic & Luthans, 1998). Studies examining school counselor self-efficacy have been a more recent addition to the literature, with reported results indicating that self-efficacy is related to school counselor gender, teaching experience (Bodenhorn & Skaggs, 2005), and supportive staff and administrators (Sutton & Fall, 1995).
In a study that extended the findings of previous self-efficacy research (Sutton & Fall, 1995), Scarborough and Culbreth (2008) examined factors that predicted discrepancies between actual and preferred practice in school counselors. Both self-efficacy beliefs and the amount of perceived administrative support predicted the difference between school counselors’ actual and preferred practice, with higher levels of support and outcome expectancy predicting higher levels of preferred intervention activities performance. In the current study, we plan to extend Scarborough and Culbreth’s work by examining the links between comprehensive elementary school counselor practice and overall school counselor self-efficacy while introducing attachment characteristics as a possible variable related to school counselor performance.
Attachment
Attachment theory describes how early experiences with attachment figures (e.g., mother) create inner representations referred to as internal working models. Those internal working models then shape patterns of behavior in response to significant others and to stressful situations (Mikulincer, Shaver, & Pereg, 2003). Adult attachment categories reflect those created in infancy and childhood and include secure, preoccupied (or anxious), dismissing (or avoidant), and fearful (both anxious and avoidant) styles (Bartholomew & Horowitz, 1991). In adults, attachment style encompasses affective responses in a variety of relationships, including co-workers, and can be activated by a number of stressful situations, including a stressful work environment (Mikulincer & Shaver, 2003, 2007).
Working effectively in a job or career contributes in meaningful ways to life satisfaction, self-esteem and social status, whereas not working effectively (and experiencing overload or burnout) can be extremely stressful and can cause serious emotional and physical difficulties (Mikulincer & Shaver, 2007). Specifically for school counselors, Wilkerson and Bellini (2006) reported that emotion-focused coping is a significant predictor of burnout, lending support to the examination of interpersonal factors in school counselor practice. To work effectively and not succumb to burnout, school counselors may have to activate self-regulatory skills associated with attachment, such as exploring alternatives, refining skills, adjusting to variation in tasks and role demands, and exercising self-control (Mikulincer & Shaver, 2007). In the field of school counseling, challenges include facing multiple demands and conflicting responsibilities (Cinotti, 2014); therefore, interpersonal communication, negotiation and adaptation become essential. Although attachment theory has received very little attention in school counseling literature (Pfaller & Kiselica, 1996), existing research suggests that various aspects of work are likely to be affected by individual differences in attachment style (Mikulincer & Shaver, 2007).
The purpose of this study was to explore demographic and interpersonal factors related to elementary school counseling practice. This research employed an associational survey research design to examine the relationships between school counselor overall self-efficacy, attachment style, and a range of performed and preferred activities in a sample of ASCA members who are elementary school counselors. Building on previous studies, we controlled for the anticipated variance in school counselor activities that might be contributed by previously identified demographic variables, including years of experience, ASCA National Model training and ASCA National Model use (Scarborough & Culbreth, 2008).
The first research question inquired about the relationship between self-efficacy beliefs and school counselor performed and preferred intervention activities that align with ASCA, controlling for the potential effect of the identified demographic variables. We hypothesized that self-efficacy beliefs would predict both school counselor preference and actual performance of these core activities, after controlling for the potential effect of relevant demographic variables. The second research question inquired about the relationship between attachment style and both counseling and non-counseling activities, controlling for the effect of the identified demographic variables. We hypothesized that school counselors who endorse higher levels of anxiety may prefer to engage in fewer intervention activities and more non-counseling activities. This could be in an effort to please others and conform to the administrative, fair share and clerical demands of the job. No hypothesis was forwarded on attachment avoidance and discrepancies between actual and preferred activities, as related research has not examined a possible relationship.
Method
Participants
The sample for this study consisted of elementary-level school counselors whose e-mail addresses were listed on the ASCA national database. We made the decision to select only elementary school counselors because of the unique emphasis on student personal and social development at this level (Dahir, 2004), as well as the distinct developmental needs of the student population that could potentially tap into school counselor attachment (Scarborough, 2005). Recruitment e-mails were sent to 3,798 ASCA member elementary school counselors through SurveyMonkey, employing a 3-wave multiple contact procedure. The original sample was adjusted to 3,550 because of undeliverable e-mail addresses. In total, 663 individuals responded to the survey, yielding a return rate of 19%. A priori power analysis using G*Power software determined that a minimum sample of 107 participants likely was necessary when conducting a multiple regression analysis with three independent variables. This G*Power calculation was based on an alpha level of .05, minimum power established at .80 and a moderate treatment effect size, and was conducted in the planning stages to inform needed sample size and minimize the probability of Type II error (Faul, Erdfelder, Buchner, & Lang, 2009). Therefore, surveys with incomplete data were completely removed from the analysis, resulting in a final sample size of 515 and a usable response rate of 14.5%.
The sample consisted of 89.6% females and 9.8% males (3 participants did not indicate gender). In terms of race and ethnicity, 86.6% were Caucasian, 6% African American, 2.9% Hispanic, 1.6% Multiracial, 1.4 % Asian/Pacific Islander, and 0.4% Native American (1.2% did not indicate race or ethnicity). The predominately female and Caucasian sample is consistent with school counseling research and reflective of the population (Bodenhorn & Skaggs, 2005).
Years of experience ranged from < 1 to 38, with a mean of 10.24 years. School enrollment ranged from 70 to 3,400 students, with a mean of 583.49 students. The large maximum enrollment number was caused by the inclusion of elementary-level counselors who were employed in K–12 schools. Counselor caseload ranged from 6 to 1,500, with the mean being 454.68 students. The mean age of respondents was 44 years, with a standard deviation of 11.02 years, and an age range spanning from 25 to 68 years. Regarding ASCA National Model (2012) training, only 8.5% reported not having received any training, with the overwhelming majority of the participants having received training from professional development opportunities sought on their own (67.6%), as part of master’s-level coursework (53.2%), or through their school district (31.5%). Only 5.2% of respondents reported no use of the ASCA National Model, with 14% reporting limited use, 33.8% some use, 31.5% a lot of use, and 15% extensive use.
Instruments
Instrumentation consisted of four measures, including a demographic questionnaire, the School Counselor Activity Rating Scale (SCARS; Scarborough, 2005), the School Counselor Self-Efficacy Scale (SCSE; Bodenhorn & Skaggs, 2005) and the Experiences in Close Relationships Scale-Short Form (ECR-Short Form; Wei, Russell, Mallinckrodt, & Vogel, 2007).
Demographic questionnaire. A demographic questionnaire consisting of 14 questions collected relevant information regarding participant age, gender, ethnicity, region, school setting (i.e., private, public) and level (e.g., elementary, middle), student enrollment, counselor caseload characteristics, degree earned, licensure and certification, years of experience and training in and use of the ASCA National Model. Demographic data were selected for inclusion based on a literature review indicating important relationships between these variables and school counseling outcomes (Scarborough & Culbreth, 2008; Sink & Yillik-Downer, 2001).
School Counselor Activity Rating Scale (SCARS). The SCARS is a 48-item scale reflecting best practice recommendations for school counselors based on the ASCA National Standards (Campbell & Dahir, 1997) and the ASCA National Model (ASCA, 2003). It was designed to measure the frequency with which school counselors perform specific work activities, and the preferred frequency of performing those activities (Scarborough, 2005; Scarborough & Culbreth, 2008). The instrument contains five sections—counseling, consultation, curriculum, coordination and “other” activities. Participants indicate their actual and preferred performance of common school counseling activities on a frequency scale (1 = rarely do this activity to 5 = routinely do this activity), including “other” non-counseling activities that fall outside the school counselor role (e.g., coordinate the standardized testing program). A SCARS total score is calculated by adding the totals from each subscale or calculating mean scores, with higher scores indicating higher levels of engagement.
The SCARS validation study supported a four-factor solution representing the counseling, coordination, consultation and curriculum categories. Analysis on the “other” school counseling activities subscale, consisting of 10 items reflecting non-counseling activities, resulted in three factors: clerical, fair share and administrative. Convergent and discriminant construct validity also were reported (Scarborough, 2005). Cronbach’s alpha reliability coefficients, as reported by Scarborough on the eight subscales of actual and preferred dimensions, were .93 and .90 for curriculum; .84 and .85 for coordination; .85 and .83 for counseling; .75 and .77 for consultation; .84 and .80 for clerical; .53 and .58 for fair share; and .43 and .52 for administrative. In the current study, the Cronbach’s alpha coefficients for actual and preferred practice were .90 and .83 for curriculum; .84 and .86 for coordination; .80 and .81 for counseling; and .76 and .73 for consultation.
The intervention total subscale in our study consisted of the composite of the counseling, consultation, curriculum and coordination subscales, with Cronbach’s alpha reliability coefficients of .91 on both the actual and the preferred use dimensions. Similar to Scarborough (2005), the “other” duties subscale, consisting of clerical, fair share and administrative duties, had moderate reliability, with Cronbach’s alpha of .63 on the actual, and .68 on the preferred. The activities total subscale consisted of a combination of all SCARS subscales, with Cronbach’s alpha being .89 on the actual and .90 on the preferred. Various studies have been conducted since the initial validation of the SCARS and support its use as a tool yielding valid and reliable school counselor process scores (Scarborough & Culbreth, 2008; Shillingford & Lambie, 2010).
School Counselor Self-Efficacy Scale (SCSE). The SCSE (Bodenhorn & Skaggs, 2005) is a 43-item
self-report instrument designed to measure school counselor self-efficacy. The SCSE uses a 5-point Likert-type scale to measure responses (ranging from 1 = not confident to 5 = highly confident) and consists of five subscales: personal and social development; leadership and assessment; career and academic development; collaboration; and cultural acceptance. A composite mean is calculated to demonstrate overall self-efficacy. SCSE responses were evaluated for reliability, omission, discrimination and group differences (Bodenhorn & Skaggs, 2005), with results supporting high reliability for the composite scale (α = .95). Analyses also indicated group differences demonstrating score validity for the scale—participants who had teaching experience, had been practicing for three or more years, and were trained in and used the ASCA National Standards reported higher levels of self-efficacy. The total scale SCSE alpha in the current study was .96.
Experiences in Close Relationships Scale (ECR)-Short Form. The ECR-Short Form (Wei et al., 2007) is a 12-item self-report measure designed to assess a general pattern of adult attachment. The ECR-Short Form is based on the longer Experiences in Close Relationship Scale (Brennan, Clark, & Shaver, 1998). Factor analysis revealed two dimensions of adult attachment, anxiety and avoidance, which have received professional consensus (Bartholomew & Horowitz, 1991; Mikulincer & Shaver, 2003). High scores on either or both of these dimensions are indicative of an insecure adult attachment orientation. Low levels of attachment anxiety and avoidance indicate a secure orientation (Bartholomew & Horowitz, 1991; Brennan et al., 1998; Lopez & Brennan, 2000; Mallinckrodt, 2000).
Internal consistency was adequate with coefficient alphas from .77 to .86 for the anxiety subscale and from .78 to .88 for the avoidance subscale, and confirmatory factor analyses provided evidence of construct validity with a two-factor model (i.e., anxiety and avoidance), indicating a good fit for the data. Reported test-retest reliabilities averaged .83. For the current study, ECR-S alphas were .75 for the anxiety subscale and .81 for the avoidance subscale.
Data Analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS Version 18), with multiple hierarchical regressions used to answer both research questions. Hierarchical regression was selected to determine the relative importance of the predictor variables, over and above that which can be accounted for by other previously identified predictors regarding school counselor service delivery (i.e., years of experience, ASCA National Model training and ASCA National Model use). Predictor variables included self-efficacy beliefs (SCSE total score), attachment anxiety (ECR-Short Form Anxiety subscale) and attachment avoidance (ECR-Short Form Avoidance subscale). Outcome variables included actual (SCARS total Actual scale) and preferred (SCARS total Preferred scale) intervention activities, “other” non-counseling activities (SCARS Other Activities scale) and the discrepancy between actual and preferred intervention and “other” activities.
Prior to analysis of the research questions, correlations were conducted among the predictor and outcome variables. Identified predictors (i.e., years of experience, ASCA National Model training and ASCA National Model use) were also correlated with the SCARS criterion variables. For the hierarchical regression, identified predictors were entered first as a block, followed by the new predictors included in this study (Field, 2009). This predetermined order of entry is congruent with Cohen and Cohen’s (1993) recommendations for using hierarchical regression and entering the demographic variables in the initial step. Additionally, the order of entry reflected the principle of presumed causal priority (Cohen & Cohen, 1993; Petrocelli, 2003). For the second step, we decided to enter attachment anxiety prior to avoidance, as we anticipated it would be more important in predicting the outcome variables (Field, 2009). Reported effect size estimates reflect the following guidelines: r of .1 (small), .3 (medium) and .5 (large); and R2 of .01 (small), .09 (medium) and .25 (large; Cohen, 1988).
Results
We first examined the correlation among the identified school counselor demographic variables (control variables) and the actual and preferred SCARS variables. Years of experience showed a small but significant positive correlation with actual intervention activities (r = .20, p < .05). ASCA National Model use showed a moderate positive correlation with actual intervention activities (r = .44, p < .05), but smaller relationships with preferred intervention activities (r = .15, p < .05). Additional correlation analysis revealed relationships among school counseling experience and the main predictor variables that were of interest in this study. For example, years of experience showed a significant, although small, negative correlation to attachment anxiety (r = -.14, p < .05). Both attachment anxiety and avoid-
ance showed negative correlations to self-efficacy (r = -.20 and -.15, p < .05, respectively). Lastly, self-
efficacy showed a small positive correlation with years of experience (r = .25, p < .05) and ASCA National Model use (r =.27, p < .05).
Self-Efficacy Predicting Actual and Preferred Intervention and Other Activities
Multiple hierarchical regression analyses were conducted to determine if self-efficacy was positively associated with actual and preferred intervention activities, after controlling for demographic variables (see Table 1). Self-efficacy was the predictor variable and actual and preferred intervention activities were the criterion variables in separate analyses. Because years of experience, ASCA National Model training and ASCA National Model use were correlated with the SCARS criterion variables, these control variables were entered as a block prior to entering self-efficacy beliefs. The model for actual activities was significant: F(1, 506) = 112.37, p < .05, supporting the hypothesis. The standardized beta between self-efficacy and actual intervention activities was .40 and the effect size based on the adjusted R2 statistic indicated that 37% of the variance in actual activities was accounted for by self-efficacy, after blocking for the control variables, a large effect size. Results for preferred school counselor activities showed a similar result, as the model for preferred activities also was significant: F(1, 506) = 78.59, p < .05. The standardized beta between self-efficacy and preferred intervention activities was .39, and the adjusted R2 indicated 15% of the variance in preferred activities was accounted for by self-efficacy, after blocking for the control variables, a medium effect size.
Table 1.
Results from hierarchical multiple regression using self-efficacy to predict SCARS actual and preferred intervention activities
|
Block 1
|
Block 2
|
| Predictor Variable |
B
|
SE B
|
β
|
B
|
SE B
|
β
|
| Actual |
|
|
|
|
|
|
| Experience (years) |
0.01
|
0.00
|
0.20*
|
0.01
|
0.01
|
0.10*
|
| A.N.M. Training |
-0.02
|
0.03
|
-0.60
|
-0.02
|
0.03
|
-0.03
|
| A.N.M. Use |
0.22
|
0.02
|
0.44*
|
0.17
|
0.02
|
0.34*
|
| Self-Efficacy |
|
|
|
0.45
|
0.04
|
0.40*
|
| R2 |
0.23
|
0.37
|
| F for change in R2 |
50.46*
|
112.37**
|
| Preferred |
|
|
|
|
|
|
| Experience (Years) |
0.00
|
0.00
|
0.04 |
-0.00
|
0.00
|
-0.05
|
| A.N.M. Training |
-0.00
|
0.03
|
-0.01 |
-0.01
|
0.03
|
-0.01
|
| A.N.M. Use |
0.06
|
0.02
|
0.15* |
0.02
|
0.02
|
0.05
|
| Self-Efficacy |
|
|
|
0.37
|
0.04
|
0.39**
|
| R2 |
0.02
|
0.15
|
| F for change in R2 |
3.92*
|
78.59*
|
|
|
|
|
|
|
|
|
Note: Analysis N = 511 (actual & preferred); * p < .05. A.N.M. denotes ASCA National Model.
Similar hierarchical multiple regression analyses were conducted using school counselor self-efficacy as the predictor variable and “other” school counseling activities as the criterion variable, after controlling for demographic variables (see Table 2). The models for preferred and actual “other” activities were both significant; F(1, 506) = 20.89, p < .05; and F(1, 506) = 13.60, p < .05, respectively. The standardized beta for actual “other” activities was .21 and for preferred “other” activities was .17. Self-efficacy accounted for (R2 =) 43% of the variance in actual “other” activities performed and (R2 =) 33% of preferred “other” activities, indicating large effect sizes.
Table 2.
Results from hierarchical multiple regression using self-efficacy to predict SCARS actual and preferred “other” non-counseling activities
|
Block 1
|
Block 2
|
| Predictor Variable |
B
|
SE B
|
β
|
B
|
SE B
|
β
|
| Actual |
|
|
|
|
|
|
| Experience (Years) |
0.00
|
0.00
|
0.02
|
-0.00
|
0.00
|
-0.03
|
| A.N.M. Training |
0.04
|
0.04
|
0.05
|
0.04
|
0.04
|
-0.05
|
| A.N.M. Use |
-0.04
|
0.03
|
-0.06
|
-0.07
|
0.03
|
-0.11
|
| Self-Efficacy |
|
|
|
0.29
|
0.06
|
0.21*
|
| R2 |
0.00
|
0.43
|
| F for change in R2 |
0.63
|
20.89*
|
| Preferred |
|
|
|
|
|
|
| Experience (Years) |
0.01
|
0.00
|
0.07
|
0.00
|
0.00
|
0.03
|
| A.N.M. Training |
-0.02
|
0.04
|
-0.03
|
-0.02
|
0.04
|
-0.03
|
| A.N.M. Use |
-0.00
|
0.03
|
-0.0
|
-0.00
|
0.03
|
-0.00
|
| Self-Efficacy |
|
|
|
0.22
|
0.06
|
0.17*
|
| R2 |
0.02
|
0.33
|
| F for change in R2 |
1.13
|
13.60**
|
Note: Analysis N = 511 (actual & preferred); * p < .05. A.N.M. denotes ASCA National Model.
Attachment Predicting Actual and Preferred Intervention and “Other” Activities
Hierarchical multiple regressions were used to assess the ability of attachment style to predict school counselor interventions and “other” non-counseling activities, after controlling for demographic variables. In our study, attachment style was measured by the ECR-Short Form (Wei et al., 2007) on two dimensions—attachment anxiety and avoidance. As in the regression analyses for counselor self-efficacy, years of experience, ASCA National Model training and ASCA National Model use were entered as a block prior to entering attachment anxiety and avoidance. Attachment anxiety, but not attachment avoidance, revealed predictive utility for the SCARS preferred intervention subscale scores, showing a negative relationship: F(1, 505) = 2.60, p < .05. The standardized beta for preferred intervention activities was -.11 and attachment anxiety accounted for only 2% of the variance for preferred intervention activities, a small effect size.
To test whether attachment anxiety was associated with discrepancies between a range of actual and preferred school counseling activities, separate regression analyses were performed. We used attachment anxiety and attachment avoidance as the predictor variables and the discrepancy score variables that were created by subtracting the actual from the preferred scores for the actual and preferred intervention activities and “other” activities subscales. As before, years of experience, ASCA National Model training and ASCA National Model use were correlated with the SCARS criterion variables and were entered as a block prior to entering the attachment variables. For intervention activities, a relationship was not supported for either attachment anxiety or attachment avoidance. However for the “other” non-counseling activities, a relationship between attachment anxiety and the actual/preferred discrepancy revealed a statistically significant result over and above that accounted for by demographic variables: F(1, 505) = 3.16, p < .05 with a standardized beta of .12. Therefore, attachment anxiety predicted a discrepancy that revealed a higher preference for performing “other” non-counseling activities. However, the effect size showed that anxiety accounted for only 1% of the variance in the “other” activities discrepancy score (see Table 3).
Table 3
Results from hierarchical multiple regression using attachment to predict SCARS intervention scores and the actual/prefer discrepancy scores for intervention and “other” activities
|
Block 1
|
Block 2
|
Block 1
|
Block 2
|
| Predictor Variable |
B
|
SE B
|
β
|
B
|
SE B
|
β
|
B
|
SE B
|
β
|
B
|
SE B
|
β
|
|
Intervention Actual
|
Intervention Discrepancy
|
| Experience (years) |
0.01
|
0.00
|
0.20*
|
0.02
|
0.00
|
0.19*
|
-0.01
|
0.00
|
-0.18*
|
-0.01
|
0.00
|
-0.18*
|
| A.N.M. Training |
-0.02
|
0.03
|
-0.03
|
-0.02
|
0.02
|
-0.02
|
0.01
|
0.03
|
0.02
|
0.02
|
0.03
|
0.02
|
| A.N.M. Use |
0.22
|
0.02
|
0.44*
|
0.22
|
0.02
|
0.44*
|
-0.16
|
0.02
|
-0.34*
|
0.16
|
0.02
|
0.34*
|
| Anxiety |
|
|
|
-0.03
|
0.02
|
-0.06
|
|
|
|
-0.01
|
0.02
|
-0.03
|
| Avoidance |
|
|
|
0.01
|
0.02
|
0.02
|
|
|
|
0.00
|
0.02
|
-0.01
|
| R2 |
|
0.23
|
|
0.00
|
0.15
|
0.00
|
| F for change in R2 |
50.46*
|
0.34
|
29.69*
|
0.33
|
|
Intervention Preferred
|
“Other” Discrepancy
|
| Experience (years) |
0.00
|
0.00
|
0.04
|
0.00
|
0.03
|
0.02
|
0.04
|
0.03
|
0.06
|
0.03
|
0.03
|
0.04
|
| A.N.M. Training |
0.00
|
0.03
|
-0.01
|
0.00
|
0.03
|
0.00
|
-0.61
|
0.31
|
-0.10*
|
-0.57
|
0.31
|
-0.09
|
| A.N.M. Use |
0.06
|
0.02
|
0.15*
|
0.06
|
0.02
|
0.14*
|
0.57
|
0.24
|
0.12*
|
0.57
|
0.23
|
0.12*
|
| Anxiety |
|
|
|
-0.05
|
0.02
|
-0.11*
|
|
|
|
-0.58
|
0.23
|
0.12*
|
| Avoidance |
|
|
|
0.01
|
0.02
|
0.02
|
|
|
|
0.29
|
0.25
|
0.06
|
| R2 |
0.02
|
0.01
|
0.02
|
0.01
|
| F for change in R2 |
3.92*
|
2.6
|
3.21*
|
3.16*
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Note: Analysis N = 511 (actual & preferred); * p < .05. A.N.M. denotes ASCA National Model.
Discussion
To date, few studies have examined how school counselor personal characteristics are linked to successful programs (Scarborough & Luke, 2008). Using a nationwide sample, we examined how self-efficacy is related to a range of school counselor activities in elementary schools and introduced attachment style as a potential variable related to school counselor practice. Years of experience working as a school counselor as well as the training in and use of the ASCA National Model in program implementation were identified from the literature as variables of importance and were included in our analyses.
As anticipated the number of years of experience was related to actual performance of intervention activities by school counselors. Also, school counselors in this sample who had received more training in the ASCA National Model were more likely to perform the intervention activities of counseling, consultation, curriculum and coordination. These activities are considered core activities for effective program implementation. Furthermore, counselors who endorsed more fully implementing the ASCA National Model within their program were significantly more likely to perform these core intervention activities and also indicated a preference for spending their time in these activities. This result is in line with previous findings supporting that counselors who incorporated the National Standards for School Counseling Programs (Campbell & Dahir, 1997) into their programs were more likely to have preferences that aligned with professional standards and actually practiced as they preferred (Scarborough & Culbreth, 2008). It is promising that over 75% of school counselors in the current study reported some use to extensive use of the ASCA National Model. The large number of counselors who reported ASCA National Model use could be indicative of a recent focus to define standards of practice and increase positive student outcomes through systematic and programmatic delivery. With regard to non-counseling activities, results did not support a relationship with ASCA National Model training and use.
Looking beyond the demographic variables, the findings of the current study support previous research that found important links between school counselor self-efficacy beliefs and program implementation (Bodenhorn, Wolfe, & Airen, 2010). In the current study, overall school counselor self-efficacy beliefs predicted the delivery of activities aligned with the ASCA National Model above and beyond the demographic variables analyzed. School counselors who believed they were capable of performing in accordance with activities aligned with the ASCA National Standards were more likely to actually perform and want to perform school counseling intervention activities consistent with the ASCA National Model.
It is interesting to note that school counselors with higher self-efficacy beliefs were more likely to perform non-counseling activities when compared to counselors with lower self-efficacy. These results suggest that counselors with higher levels of self-efficacy beliefs may not discriminate between intervention and “other” non-counseling activities, by performing both more frequently. Highly efficacious school counselors may simply do more, whether or not the activity aligns with ASCA recommendations. As demands for school counselors increase and current expectations for school counselors do not perfectly align with professional best practices (Cinotti, 2014), highly efficacious school counselors may tackle all duties earnestly in order to address their responsibilities.
In the current study, attachment anxiety negatively predicted school counselor preferred engagement in intervention activities (i.e., counseling, consultation, curriculum, coordination), indicating that anxiously attached school counselors actually preferred to perform fewer intervention activities. Additionally, school counselor attachment anxiety predicted a discrepancy between actual and preferred activities that are considered outside the scope of school counseling practice, including clerical, administrative and fair share responsibilities. When considering the relationship between attachment anxiety and this discrepancy, which revealed a higher preference for performing these “other” activities, there are a few possible explanations. Perhaps anxiously attached counselors reporting a greater discrepancy on the “other” subscale find it more difficult to align their identity with the counseling professional identity model promoted by ASCA. Although these non-counseling activities do not align with ASCA recommendations, they are nevertheless expected and valued by supervisors. Research has suggested that anxiously attached individuals may tend to take on additional work obligations as a way to please others and tend to be motivated by approval of colleagues and supervisors (Hazan & Shaver, 1987). Additionally, anxiously attached workers seek close relationships with their colleagues and supervisors and have more difficulty resisting unreasonable demands in the workplace (Leiter, Day, & Price, 2015). Given that school administrators directly influence the assignment of inappropriate duties performed by school counselors, and that strong advocacy and leaderships skills are essential to negotiate an identity and role that is more aligned with ASCA recommendations (Cinotti, 2014), anxiously attached school counselors may find it more difficult to test those relationships and may instead endorse the identity expected by their supervisors. Indeed, the literature points out that school administrators perceive school counselors as operating mainly from an educator—versus a counselor—professional identity (Cinotti, 2014).
There was a low variability in attachment scores of this particular sample (i.e., school counselors endorsed relatively high levels of self-efficacy and low levels of attachment insecurity), which could have contributed to the results of this research. Within the clinical training component of their education, school counselors are taught the importance of ongoing self-exploration and to develop awareness of their responses within the context of clinical practice. It is possible that education and training in the importance of self-awareness could interrupt effects on school counselor practice that are related to higher levels of attachment anxiety.
Counselors in this sample consistently indicated that they preferred to spend more time in intervention activities that are in keeping with best practices and are related to positive outcomes for students and preferred to spend less time in non-counseling related activities. When compared to other research using the SCARS, they also reported engaging in fewer non-counseling activities. As performing non-counseling activities is associated with burnout in school counselors (Bardhoshi et al., 2014), this is a positive finding that might be reflective of the current direction of the profession.
Study Limitations
The potential for self-selection and social desirability bias was a limitation of this study. Only elementary school counselors who were ASCA members were invited to participate. It is possible that those members who did volunteer to participate may differ in a variety of ways from those individuals who did not respond. Given the $115 membership fee to join the association, it is possible that counselors from wealthier school districts, with higher salaries or access to a counseling budget assisting with the membership fee, are more heavily represented. School counselors who chose to become members of ASCA may vary distinctly in work-related performance, self-efficacy beliefs and attachment style than those counselors who chose not to become members of the association. ASCA members likely have more professional development opportunities and more exposure to information regarding best practices, which could impact both their self-efficacy beliefs and practice.
Despite our use of multiple contact procedures to obtain an acceptable response rate, a limitation worth noting is the lower response rate. Lower response rates are often noted for online surveys (Dillman, Smyth, & Christian, 2014), including in the field of counseling (Granello & Wheaton, 2004). Although we received over 200 undeliverable e-mails, which reduced the original sample size, there is no way to accurately estimate how many individuals actually received the survey in their inbox (Granello & Wheaton, 2004). It is indeed possible that spam-filtering software resulted in many invitations not reaching their intended recipients. Therefore, our reported response rate represents a conservative estimate (Vespia, Fitzpatrick, Fouad, Kantamneni, & Chen, 2010). In addition, it was assumed that the attrition of 100 participants was likely the result of the time required to complete the survey. Our analysis supported that there were no statistically significant differences between the two groups (i.e., completers and non-completers) on demographic variables and that our final sample size was adequate for the selected statistical tests. However, readers should use caution when generalizing the results of this study to all elementary school counselors. A final consideration is that causal relationships cannot be derived from the results of this study, as the research design was relational in nature.
Implications for School Counseling Practice
Previous studies have indicated that higher levels of school counselor self-efficacy are positively associated with higher levels of comprehensive program implementation (Bodenhorn et al., 2010). For many, the route to increased self-efficacy is through personal and vicarious accomplishments (Bodenhorn et al., 2010; Scarborough & Culbreth, 2008; Sutton & Fall, 1995). Therefore, opportunities to learn and practice the skill set specific to school counseling must be promoted in the education and training of students.
School counselor educators have a crucial role in ensuring that future school counselors have a strong foundation with which to begin their careers. Counselor education programs have often not provided adequate preparation for school counselors because there has been incongruence between their training and their actual roles in schools (McMahon, Mason, & Paisley, 2009). A novice school counselor who has had education and training that is consistent with his or her actual work role will have greater chances of acquiring increased self-efficacy from the start. In a cascade, self-efficacy will likely promote stronger program implementation and, in turn, positive student outcomes.
More specifically, requiring trainees to provide a range of services will support the transition from training to work. Trainees need opportunities to provide specific interventions (e.g., counseling individuals and groups, teaching classroom lessons) while also evaluating the impact of these interventions, teaching them how to use data in their programs and potentially boosting self-efficacy beliefs (Akos & Scarborough, 2004). Trainees should also be given opportunities to engage in coordination activities to gain experience in the organizational aspects of a comprehensive developmental school counseling program. Finally, counselor educators who supervise internship courses must maintain strong communication with site supervisors to ensure continuity and appropriate trainee experiences.
Although effect sizes related to attachment characteristics in this study were small, they imply that attachment theory could be a useful adjunct to understanding school counselor practice. Using attachment concepts as a guide for supervision or structured professional development opportunities could assist school counselors’ ongoing efforts to understand their own behavior and motivations in the work setting. Graduate coursework specific to attachment constructs has the potential to be a useful component of school counselor education, especially because the cultivation of healthy interpersonal relationships has a tremendous potential to facilitate positive change in schools.
Recommendations for Future Counseling Research
The moderately strong association in this study between school counselor self-efficacy and activities recommended by the ASCA National Model indicates that understanding the factors affecting school counselor self-efficacy warrants further attention. Research outside the field of school counseling has identified a positive relationship between attachment security and higher levels of competence and self-efficacy beliefs (Mikulincer & Shaver, 2007). Given that self-efficacy was significantly negatively correlated to both attachment anxiety and avoidance in this study, additional studies examining these relationships may clarify possible connections between school counselor self-efficacy beliefs and attachment characteristics. We did not examine whether SCSE subscales were differentially related to school counselor activities. Doing so could identify professional areas about which counselors feel most efficacious and those that need bolstering. Explaining the reasons some school counselors perform more successfully is an enduring goal of counseling research (Sutton & Fall, 1995).
Our results did indicate significant relationships between attachment anxiety and school counselor practice. Specifically, attachment anxiety predicted a lower preference for intervention activities, as well as a discrepancy between actual and preferred “other” non-counseling activities that revealed a higher preference for performing them. Although small, these results could lead to further understanding of the factors related to differences in school counselor practice. As this study has taken a broad view of how school counselor practice could be affected by attachment dimensions, qualitative studies examining the unique experiences of anxiously attached counselors in their work environment have the potential to reveal important perspectives. Identifying how attachment style may contribute to the endorsement and performance of specific intervention activities could lead to a greater understanding of school counseling practice.
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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Kimberly Ernst is a counselor in independent practice in Washington, DC. Gerta Bardhoshi, NCC, is an Assistant Professor at the University of Iowa. Richard P. Lanthier is an Associate Professor at George Washington University. Data for this article originated from the first author’s doctoral dissertation. Correspondence can be addressed to Gerta Bardhoshi, College of Education, N352 Lindquist Center, Iowa City, IA 52242-1529, gerta-bardhoshi@uiowa.edu.
