Using Pair Counseling to Improve the Cost-Effectiveness of College Career Counseling

Oct 15, 2014 | Article, Volume 3 - Issue 2

Mary-Catherine McClain, James P. Sampson

As the demand for career counseling services grows, the need for accountability rises, and the availability of funding decreases, it becomes more critical that practitioners utilize cost-effective interventions and alternative forms of treatment. One option for improving access to all clients while concurrently reducing costs involves using approaches based on collaboration between clients. Pair counseling, a brief intervention based on pairing two individuals of opposing orientations, can be implemented to improve access, promote social justice, and enhance the overall delivery of career services. This article further examines how career theory can be translated into actual practice. Implications for program development and future research are addressed.

Keywords: career counseling, pair counseling, cost-effective interventions, alternative treatments, brief intervention, social justice, program development

Career counselors are struggling to find more cost-effective, accessible interventions while simultaneously dealing with budget cuts and demands for accountability. As noted by Sampson, Dozier, and Colvin (2011), the nature of interventions (e.g., group counseling, workshops) and practitioners (e.g., teachers, counselors) are two key factors associated with cost. While specialized resources and individual counseling may be necessary for clients lacking readiness for decision-making, it is important to consider alternatives when assisting clients with higher levels of readiness or proficient decision-making skills. When level of client readiness is assessed and the appropriate service delivery option identified (e.g., individual, group, self-help), accessibility will be maximized, costs will be minimized, and practitioners will be better prepared to meet the heightened demand for services.

The purpose of this article is to provide a rationale for implementing pair counseling to maximize the number of individuals who can receive career assistance, while concurrently enhancing the cost-effectiveness and overall quality of career service delivery. This article examines career counseling and how career theory has been translated into practice, the effectiveness and relative costs of interventions utilized in career counseling, and suggestions for using pair counseling and evaluating its efficacy.

Career Development, Theory and Practice

Career counseling provides individuals with critical tools for improving self-understanding, occupational knowledge and career exploration behavior in order to set appropriate vocational goals. It also helps individuals meet their aspirations by identifying a sense of life purpose and direction. The practice of career counseling includes a unique history of more than 90 years, which incorporates principles related to counseling and career theory (Super, 1992).

Career theory plays an important role in improving the overall practice of career counseling. For example, the theory provides a basis for selecting interventions and information to effectively deliver services (Brown, 2002). Research conducted by Parsons (1909) during his work with adolescents serves as one factor that increased support for career development and interventions among school educators. Parsons emphasized the importance of self-knowledge (e.g., abilities) and knowledge about the world of work. Similarly, Strong (1927) highlighted the importance of connecting student interests to occupations, and Holland (1973) advocated finding occupational environments that were congruent with individual personality types.

Since the early 1980s, career theories and counseling roles have expanded from a strictly vocational emphasis toward a more holistic picture to meet the diverse and cultural needs of all clientele (Lee & Johnston, 2001; Parmer & Rush, 2003). Due to the rapid transformation of social and economic structures in the 21st century, career counselors have recognized the importance of utilizing dynamic interventions and new service delivery models that have emerged in response to this challenging context (Amundson, 2006). While the field of career theory has experienced considerable growth, research suggests the translation of theory into practice remains inadequate and inconsistent (Miller & Brown, 2005). Pair counseling (discussed in depth later in this article) represents one dynamic, holistic and brief-service delivery approach that could be used to help college students make more effective career decisions through the development of enhanced self-knowledge and occupational knowledge.

Interventions, Efficacy and Costs

In light of recent accountability requirements and reductions in state funding, practitioners are experiencing increased pressure to demonstrate the effectiveness of their services on client outcomes (Wampold, Lichtenberg, & Waehler, 2002). Furthermore, continued funding is highly associated with providing data on the efficacy of career interventions. The current literature suggests that career counseling interventions are effective and promote career development in clients receiving services (Whiston, 2002). Similarly, a meta-analysis performed by Hughes and Gration (2006) found that career decision-making behaviors, career-related knowledge and career maturity improved following exposure to career services. To continue examining the effectiveness of career counseling interventions, it is critical that policies are implemented in which practitioners are allocated adequate financial resources and time for evaluation purposes. Equally important is developing and testing more cost-effective models of service delivery, which ultimately promotes social justice.

Social Justice

Common themes within social justice include advocating for equal access and distribution of resources in society for both underprivileged and more fortunate individuals (Sampson et al., 2011). As mentioned above, the costs related to providing interventions may serve as one factor limiting the accessibility of services—making such costs a social justice issue. For example, individual counseling is more expensive and time consuming than other modalities, yet it appears to be the most widely accepted and used practice (Sampson et al., 2011). As the demand for services grows and the need for accountability rises, it becomes even more critical that practitioners are proactive and utilize alternative forms of treatment. One option for improving access while concurrently reducing costs involves using approaches based on collaboration between clients (Sampson et al., 2011). The following section explores the effectiveness of utilizing two nontraditional forms of counseling within the field of higher education as well as the advantages and disadvantages of the approach.

Counseling Modalities

Some career counselors have shifted focus to helping clients through collaborative techniques rather than implementing interventions that assist individuals independently (Thrift & Amundson, 2005). For instance, Lee and Johnston (2001) argued that the future success of career services and work performance is dependent upon effective collaboration, interdependence and relationships skills in which clients function as co-learners. In order to create more flexible interpersonal arrangements and reduced time constraints when providing support, guidance and information to clients, researchers in a variety of fields have developed creative treatment alternatives.

Peer Tutoring

Over the past two decades, research (Jekielek, Moore, & Hair, 2002) in peer tutoring has increased dramatically due to the method’s economic advantages (e.g., teaching larger numbers of students), political benefits (e.g., facilitating egalitarian thinking), social gains (e.g., improving interpersonal skills), and positive outcomes (e.g., promoting empowerment). Furthermore, students become active learners, receive immediate feedback, achieve greater commitment, and experience increased motivation (Schunk, 1987). For example, Maxwell (1990) showed that peer tutoring and counseling improved academic achievement, increased confidence, and lowered student anxiety levels among tutees. Likewise, Topping, Watson, Jarvis, and Hill (1996) found that students in dyadic reciprocal tutoring groups reported less stress, higher learning and more positive self-concepts when compared to a randomly assigned control group. The mentoring or tutoring relationship also allows for direct assistance with career and professional development, while it concurrently supports emotional and psychological growth (Jacobi, 1991). On the other hand, peer tutoring does have disadvantages: training students to serve as teachers consumes extensive time, and the quality of interaction may be poor if students are not matched appropriately (McDonnell, 1994). Additionally, students may give incorrect information when not under the supervision of a professional.

Collaborative Learning

One form of instructional design typically utilized within university contexts is collaborative learning (Yang, 2006). Specifically, students actively work together in groups of two or more to complete learning tasks and solve problems. More recently, dyads or pairs of students have served as the primary functional unit for collaborative learning. Slavin (1996) advocated that individuals learn better as other peers prompt metacognition, facilitate participation in cognitive activities, and provide validation. Additionally, diffusion of responsibility is minimized because only two students are working together. Improving access to interventions and reducing costs are further benefits of implementing collaborative-based approaches. On the other hand, without the role of a more advanced facilitator, students may experience difficulty completing complex tasks or have insufficient resources to solve problems.

In summary, peer tutoring and collaborative learning represent different modalities with similar underlying theoretical foundations that can be applied when assisting college students with career decisions. However, one must consider a number of significant limitations prior to use. For example, one shortcoming of each approach is the failure to directly consider developmental levels and cognitive abilities of respective clients (Horton, 2008). Pair counseling could be considered as a more cost-effective approach that incorporates strengths found in the above two modalities as well as includes interventions fostering developmental and cognitive growth under the supervision of a trained practitioner.

Pair Counseling

Pair counseling is a structured, short-term developmental intervention in which two persons of opposing intrapersonal orientations (e.g., shy versus aggressive) are matched in a counseling relationship and experience dyadic interactions within a secure environment, guided by a trained practitioner (Karcher, 2002). Pair counseling also incorporates principles of developmental psychology, play therapy and social psychology. Additionally, it is holistic, contextual, and serves as a potential preventive framework for college students seeking career counseling services and resources. Finally, it includes assumptions found in the above modalities (e.g., learning is active, depends on rich contexts, and is inherently social) and allows pairs to function under the guidance, structure and supervision of a trained counselor. However, pair counseling has not been empirically tested within a career center setting or with college/adult populations. Instead, the majority of research investigating the effectiveness of pair counseling has been conducted using children and adolescents in residential or juvenile settings (e.g., middle schools, prisons) (Selman & Schultz, 1990). In the subsequent paragraphs, the theoretical foundation and respective evaluation outcomes are addressed followed by a description of core techniques, roles of the counselor, and assessment measures used in practice. It also should be noted that this article first examines pair counseling with children, and later explores how it can be used when serving adult populations seeking career services.

Theoretical Orientation       

The mechanisms of change by which pair counseling occurs can be broken down into three theoretical categories: social perspective taking, interpersonal negotiation and interpersonal orientation. More than 50 years ago, Piaget (1965) proposed that peers and supportive relationships are critical for appropriate development. Additionally, researchers suggest that parents, educators and professionals cannot provide these friendships in the same manner or quality that peers are able to achieve (Selman, Levitt, & Schultz, 1997). Selman (1980) and his colleagues developed a model of interpersonal understanding based on the above rationale, defined as the ability to “understand social situations in terms of the multiple perspectives of the individuals involved” (Selman, 1980, p. 302). Egocentric thinking, second-person perspective, perspective coordination (e.g., capacity for abstraction) and negotiation strategies represent the four levels described in Selman’s perspective-taking development model. Persons develop this sequence of social perspective-taking over time. Successful resolution of all levels suggests that individuals can identify and understand what is best for the overall social relationship as well as resolve relationship conflict (Selman, 1980).

Each of the above perspective-taking abilities further correlates with a specific type of interpersonal negotiation strategy (often utilized to resolve interpersonal conflicts). Additionally, these strategies can be described in terms of orientation and maturity (Selman & Schultz, 1990).  For example, individuals who vaguely identify perspectives different from their own and focus only on their own wants are likely engaging in unilateral (level 1) actions while individuals operating at a second-person perspective use reciprocal (level 2) negotiation strategies (e.g., cooperation, deal making). A third-person perspective relates to demonstrating collaborative actions (level 3) that accommodate one’s own needs as well as the partner’s (Karcher, 2002). A final component of Selman’s (1980) model relates to specific interpersonal orientations, or how individuals approach relationships. Specifically, some students “give in” during peer interactions (other-transforming) while others manipulate and threaten peers to meet their own needs (self-transforming).

Research suggests that aggressive and withdrawn individuals have immature negotiation strategies and poor perspective-taking abilities when compared to age-related peers (Selman, 1980). As a result, one purpose of pair counseling is helping persons adaptively use both self- and other-transforming strategies to create perspectives that satisfy each student’s needs. Related goals include increasing social-cognitive skills (e.g., perspective taking and problem solving), promoting interpersonal understanding and fostering social maturity (Schultz & Selman, 1998). Finally, working in collaborative pairs can significantly enhance student learning while simultaneously increasing the opportunity for corrective/constructive feedback (Slavin, 1996). For example, students working in dyads can increase the opportunity for cognitive disequilibrium—with the ultimate outcome of promoting perspective-taking ability, intellectual growth, deeper perspectives and reasoning.

Previous Findings and Outcomes

How does an individual benefit from pair counseling, and to what extent can this approach facilitate psychological, social, emotional, vocational and overall well-being? Over the past two decades, several researchers have explored these questions in residential and outpatient contexts, and most recently in academic settings. Qualitative reports—largely based on case studies and quantitative research typically using empirical designs—demonstrate pair counseling as a powerful intervention that significantly contributes to positive youth outcomes (Schultz, 1997).

Youth exhibiting severe aggression, withdrawal or other disruptive behavioral patterns (e.g., ADHD) are commonly referred for treatment, whether in outpatient or residential settings.  Research also suggests that troubled children experience difficulty interacting with peers, exhibit low social competence, and lack psychological resilience (McCullough, Wilkins, & Selman, 1997).  Based on this premise, Karcher & Lewis (2002) conducted a pilot study examining the effects of pair counseling with patients receiving inpatient hospitalization services. Results demonstrated significant reductions in aggressive and delinquent behaviors as well as increases in cognitive development.  In essence, persons diagnosed with externalizing disorders (e.g., oppositional defiant disorder) learned how to make better decisions, resolve conflicts, and achieve higher interpersonal understanding when treated within a pair counseling context because it provided an avenue for self-reflection and peer interaction. Advantages of pair counseling also are effective for individuals experiencing internalizing symptoms such as depression, immaturity or social anxiety.

Schultz (1997) investigated the use of pair counseling among two adolescent girls—one more dominating and forceful, and the other more withdrawn and shy. The context of pair counseling appeared to enable the girls to identify, share and normalize feelings for one another. Furthermore, pair counseling served as a primary vehicle for allowing these youth to develop assertiveness and feel acceptance. Pairing also facilitated the acquisition of appropriate social skills among children diagnosed with ADHD as it promoted goal setting and a context in which self-control could be established. Finally, research indicates that pair counseling fosters understanding between individuals from diverse cultural or ethnic backgrounds.

Schneider, Karcher, and Schlapkohl (1999) published a case study that illustrated the benefits of implementing pair counseling when treating individuals from two different racial backgrounds. Specifically, this modality was utilized when two students of varying ethnic backgrounds were referred for counseling due to awkward and immature social skills. Over the course of treatment, the pair reflected and discussed shared experiences—eventually leading to decreased social isolation and stress experienced at school. It also was reported that the benefits extended beyond the school setting and further enhanced the students’ relationships with their respective families. Although the current research supports the use of pair counseling to treat externalizing and internalizing symptoms, no research has empirically investigated the use of pair counseling as an intervention for college students seeking career services. A potentially promising approach would be to adapt the technique of pair counseling for college students engaging in the career decision-making process.

Matching in Pair Counseling

How does one optimally match persons in pair counseling? For counseling to be most effective, individuals with opposing interpersonal orientations and developmental needs should be matched (Kane, Raya, & Ayoub, 2002). It also becomes easier to facilitate problem solving when persons exhibit divergent styles. Base pairs are typically matched in terms of different negotiation preferences—one student who is forceful or demanding may be matched with another student who expresses timid or shy behavior. Research further suggests that the weaknesses and strengths of each individual can complement the other person’s area of strength or weakness (Karcher, 2002). For example, a college student who is easily distracted may learn to relate and work better with others after being matched with a student who is attentive and detailed oriented; or, a more cautious student could be matched with an impulsive individual. Based on these examples, it seems that incorporating pair counseling and matching pairs can foster collaboration, active learning, and new ways of thinking about resolving career concerns. Also, from a social justice perspective, this type of counseling allows more clients to receive services.

Pair Counseling Techniques

While matching students serves as the foundation for progress and relationship formation, a secure environment must be established for these relationships to flourish. To improve the accuracy and overall effectiveness of pair counseling, Karcher (2002) prepared a comprehensive manual to standardize specific pair techniques and procedures. For example, counseling sessions should be conducted in the same place and at the same time each week—for 50 minutes. Equally important is establishing rules, discussing goals and describing the outline of each session (Barr, Karcher, & Selman, 1997). It also is common for pair partners to choose which activities to perform during the session using negotiation strategies.

In the beginning of each session, the practitioner reviews successes and failures of previous meetings in order to foster reflections and improve session discussions. Next, matched pairs engage in the agreed upon activity or game while the counselor remains nondirective, purposely focusing on the interaction between the pair. Throughout this time, the counselor also helps negotiate conflicts, encourages the articulation of different points of view, and assists in developing solutions to problems. During the last 15 minutes of the session, the counselor becomes more directive to facilitate reflections and to discuss how conflicts could be handled differently in the future (Karcher, 2002). Finally, examples of cooperation and assertiveness occurring within the meeting are described and pairs are typically asked to discuss feelings, thoughts or behaviors that contributed to the success of the session.

In order to promote perspective-taking and foster developmental maturity for both individuals in the pair, the practitioner can employ empowering, linking and enabling during specific interactions, as conflict arises or at the conclusion of each session (Karcher, 2002). Empowering is often utilized for impulsive persons who experience difficulty articulating feelings or identifying beliefs, goals and desires. A person gains a sense of self-efficacy as the counselor reflects needs and subsequently empowers the person to achieve a more differentiated point of view. After a person recognizes and acknowledges personal interests, linking helps the pair coordinate different social perspectives. Additionally, the counselor may need to model or break down the conflict into smaller pieces so that a goal is identified and subsequently agreed upon. Next, the pair strives to generate alternative solutions with the ultimate goal of implementing a mutual strategy. In essence, the pair works together to solve a conflict that is satisfying for both parties. Enabling serves as a final intervention that encourages the matched pair to recognize long-term consequences of individual actions on their mutual relationship. For example, reviewing disagreements, processing interactions, and resolving differences serves as one technique for increasing collaboration, support and respect between the pairs.

Pair Counselor Roles

Fostering relationship development between two individuals and maintaining relationship functions such as autonomy and intimacy represent important counselor roles (Karcher, 2002). Another role relates to enhancing social skills. In other words, a pair counselor offers support during peer interactions and uses opportunities occurring within the session, peer play and guided reflection to promote perspective taking, encourage negotiation, resolve conflict, and enhance social skills.

After establishing a secure atmosphere and explaining the specific goals of pair counseling to each partner, the counselor devotes significant effort to promoting perspective taking and interpersonal understanding. Counselors employ specific techniques in order to accomplish this goal, such as empowering, linking and enabling, as discussed previously. It should be noted that each technique corresponds to levels of perspective taking that are just above the pair’s current social and maturity level (Selman & Schultz, 1990). Other guidelines for ensuring a successful session include incorporating directive and nondirective techniques, accentuating positive interactions, and promoting connectedness between sessions.

Assessment in Pair Counseling

Assessing and evaluating pairs serves as a final function for pair counselors. A variety of evaluation measures have been developed and tested to determine the efficacy of pair counseling. Furthermore, researchers and practitioners recognize that assessment should be comprehensive, incorporating multiple points of view and several measures (Schultz, 1997). Commonly used measures to assess social skill competence and interpersonal understanding include self-reports, interviews, observational checklists, school performance data and empirically-based questionnaires. For example, the Friends’ Dilemma Interview (Selman, 1980) measures perspective-taking ability, conflict resolution and interpersonal understanding, while the Interpersonal Negotiation Strategies Interview (INS; Schultz, Yeates, & Selman, 1989) measures interpersonal autonomy. In terms of questionnaires, the Relationship Questionnaire (Schultz & Selman, 1998) presents 12 scenarios that assess personal meaning of relationships and self-reported action, while the Persons-in-Pairs Questionnaire (Schultz, 1997) explores the experience of pair counseling, feelings about being a pair partner, and things learned as a result of participating in pair counseling. Other scales include the Pair Therapy Process Scale (Selman, Watts, & Schultz, 1997) and the Community-Oriented Programs Environment Scale (Moos, 1996).

An Application of Pair Counseling in College Career Counseling

As noted by Karcher (1997), specific goals of pair counseling are a function of the context in which treatment is employed. Pair counseling has demonstrated its effectiveness with children, and the present authors propose that pair counseling could similarly be employed and be equally effective within a college career center to support freshmen and upperclassmen coping with academic or psychosocial transitions.

A Proposal for Adapting Pair Counseling at the University Level

Pair counseling serves as one intervention tool career counselors can utilize when assisting college students during stressful transitions, whether for the purpose of decreasing commitment anxiety and decision-making confusion when choosing a major, researching jobs, or applying to graduate programs. As research suggests that psychosocial development is necessary for successful performance in academic and vocational contexts, it seems that one advantage of pair counseling is fostering psychosocial development in college students (Deptula & Cohen, 2004; Hinkelman & Luzzo, 2007). For example, relationships formed during the pair counseling process are likely to result in students learning how to share feelings, resolve differences, develop identities, gain feelings of autonomy, and manage thoughts on a deeper level. Likewise, based on Schultheiss’s (2000) relational career counseling model, the facilitative nature of attachment relationships between students can be used for connecting personal, career and social domains—ultimately enhancing adjustment and overall development. This technique also fits well with more recent career theories that have emphasized a more holistic perspective when serving clients. Pair counseling further represents an avenue for translating theory into practice.

A second strength of pair counseling is its ability to help college students identify and learn the perspective of other college students from all cultural, ethnic, social, academic, class and religious backgrounds. As a result, students are likely to receive exposure to alternative points of view, develop diverse problem-solving strategies, and exhibit advanced decision-making skills. However, differences exist between pair counseling and approaches based on individual and group counseling.

Although individual counseling is effective for treating numerous problems and disorders, it does not provide students with direct social functioning with peers. This serves as one limitation for career counselors assisting students seeking interviewing tips or guidelines for resume writing. For example, students working in pairs on these tasks are likely to benefit because of the increased opportunity for reflection and development of interpersonal competence. Similarly, group counseling may not provide students with a direct opportunity to learn or interact with one another. For example, conflicts or disagreements may affect an entire group, but not a specific relationship. Alternatively, the structure of pair counseling protects against the opportunity for students to become overwhelmed or overstimulated by group processes while simultaneously providing clients with resources for support and coping (Karcher, 1997). Third, the approach of pair counseling addresses the developmental level of each pair member and has specific interventions to further facilitate cognitive growth. A final rationale for implementing pair counseling within a college career setting relates to cost-effectiveness. Specifically, as the number of students seeking career services continues to grow and as the number of staff and other resources remains the same or declines, it becomes critical to implement interventions that meet or fulfill this need.

Matching Pairs, Sessions and Techniques

Several factors should be considered when determining pairs. Based on the current literature, the most effective pairing typically occurs among same-gender partners and individuals sharing similar academic or cognitive abilities. These similarities likely increase collaboration, communication and comfort between individuals because the individuals are seen as equal partners. Furthermore, clients are often matched according to opposing interpersonal orientations as it fosters more effective problem solving and discussion. Similarly, clients sharing similar interests, work experiences and occupational goals are generally appropriate pairs. Pairing also is a function of the career service requested; clients selecting a college major have different needs than clients applying for employment or creating a portfolio. It should be noted that the above represent hypotheses, and because no research has empirically investigated pair counseling in a career setting or used content related to vocational decision-making, these suggestions should be experimentally tested. Furthermore, researchers should consider alternative pairings (e.g., cross-age pairs) to identify which factors are most important when matching clients. Following the matching process, how are sessions conducted, techniques implemented and goals achieved?

Increased attention and research efforts are needed for answering the above questions because minimal research has examined pair counseling using brief interventions or drop-in advising services for career counseling. As the majority of clients seeking career services rarely “drop by” more than three or four times in a semester, and often spend less than one hour per session, it seems that one option is intervening early and specifically targeting students who are at-risk for dropping out of college early (e.g., undecided major, first-time-in-college students) or who are already experiencing difficulty in their academic programs. After identifying at-risk students, similar techniques of empowering, linking and enabling should be employed.

Stumbling Blocks and Potential Ethical Issues

While pair counseling has demonstrated efficacy in treating a variety of disorders and across a range of clinical settings, several potential problems have been noted within the literature. First, mismatching among partners may decrease treatment effectiveness; opportunities for conflict increase when interpersonal orientations, levels of maturity and perspective-taking abilities differ significantly between partners (Karcher, 1997). Furthermore, without an adequate level of rapport and security, pairs may find it difficult to communicate, interact and be honest with one another. Based on these findings, it becomes critical that career counselors develop strategies for matching pairs. For example, the Career Thoughts Inventory (CTI; Sampson, Peterson, Lenz, Reardon, & Saunders, 1996) could be utilized to match students of varying levels of anxiety, decision-making confusion and external conflict, or it may be more appropriate to match pairs based on Myers-Briggs Type Indicator (MBTI) personality types. The CTI could also be used as an outcome measure to evaluate the effectiveness of pair counseling. Similarly, educators and researchers should consider how they might pair students who are enrolled in an undergraduate career development course and thus already have pre-existing relationships. Alternatively, how might it work for two members of an organization (e.g., Greeks) to engage in pair counseling?

Disclosing too much information (e.g., making the other partner uncomfortable), breaking confidentiality, and prematurely terminating the sessions represent additional concerns. For example, if an individual shares information outside of the counseling relationship, the other individual may develop mistrust issues or be reluctant to reveal feelings or opinions in future sessions. In order to reduce the likelihood of these ethical problems occurring, it is important for counselors to maintain structure, develop rules, and take notes following each session. When facing complex situations, counselors should consult with others, seek supervision, and use resources.

Future Directions

An important first step for researchers is to conduct studies beyond externalizing disorders and internalizing problems to more cognitively advanced and psychosocial issues encountered by college students and young adults. For example, the influence and potentially positive impact pair counseling has when assisting clients making career decisions and selecting educational options based on vocational goals represents a cognitive example that could be explored more closely by future researchers. Alternatively, researchers could examine how social support between pairs fosters career readiness and autonomy; would an individual feeling discriminated against or afraid to “come out” experience more comfort in making decisions when involved in a positive social relationship? Similarly, the literature and methodology of collaborative learning can be incorporated when assisting clients under a pair counseling approach. Whether pairs work together to explore a significant question (e.g., what college major should I choose?), resolve a problem (e.g., how to write a resume) or complete an activity on the Internet (e.g., research occupations) to make a more informed career choice, the principle components and methodology used for collaborative learning will be essential as researchers move forward in better understanding and implementing pair counseling. As with collaborative learning, these activities should be clearly defined, and individuals must feel supported and validated, but also challenged (Yang, 2006).

Another area for future research concerns the issue of social justice. Researchers could evaluate the cost-effectiveness of pair counseling over an academic year by comparing the number of clients served, the duration of each session, and specific outcomes associated with participating in the pair counseling process (e.g., career satisfaction, career readiness, reduction in dysfunctional thoughts).

Formal quantitative and qualitative research designs are needed to evaluate the effectiveness of pair counseling (Horton, 2008). Specifically, researchers should focus on employing true experiments or at least quasi-experimental designs that incorporate random assignment and comparison groups. Similarly, it is important to collect information over a longer intervention period that includes multiple data collection dates and assessment instruments measuring self-esteem, career readiness, and anxiety. In addition to these areas for future research, it would be beneficial to have a larger number of pairs across a variety of ethnicities, genders, academic levels (freshman through graduate student), and college majors (Horton, 2008). Third, it would be beneficial to explore outcomes of pair counseling for different disorders and across different levels of perspective taking/negotiation to determine which pairings are most effective. Finally, it is important to explore the effectiveness of pair counseling using a variety of total sessions. Researchers could evaluate whether paired students benefit from 1–3 sessions, which is typical practice at career centers advocating brief-staff assisted services, or whether a more traditional 10–13 sessions is necessary for positive treatment results.

Conclusion

Pair counseling could assume an important role in the area of career intervention, as it represents an approach that facilitates dyadic, positive social interactions between two clients. Through collaborative discussions among matched pairs, and under the guidance of a professional counselor, students could identify transferrable skills, select majors, and learn how to make more effective career decisions. Similarly, pairs could provide emotional support to one another while implementing career choices and/or discussing options for reducing career barriers and feelings of anxiety. In addition to bridging the gap between theory and practice, pair counseling represents a cost-effective approach that would enable more college students seeking career services to be served. Future research is needed to determine what types of clients benefit the most and for what career problems this approach is most effective.

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Mary-Catherine McClain is a predoctoral intern at Johns Hopkins University Counseling Center. James P. Sampson, NCC, NCCC, is the Mode L. Stone Distinguished Professor of Counseling and Career Development, Associate Dean for Faculty Development and Administration, and Co-Director, Center for the Study of Technology in Counseling and Career Development, College of Education at Florida State University. Correspondence can be addressed to Mary-Catherine McClain, 3003 North Charles Street, Suite S-200, Baltimore, MD 21218, mcmmcclain@gmail.com.

Millennial Counselors and the Ethical Use of Facebook

Oct 15, 2014 | Article, Volume 3 - Issue 2

Leah Brew, Joseph M. Cervantes, David Shepard

The use of social networking sites (SNS), and Facebook in particular, seems to be on the rise (Salaway, Nelson, & Ellison, 2008). The majority of users tend to be from the millennial generation (Hazlett, 2008), as are the majority of graduate counseling students. This discussion explores several areas regarding the use of Facebook. First, we review the literature on why students from the millennial generation are such avid users of Facebook. Second, we explore privacy settings: how Millennials establish privacy settings and what demographic factors may be correlated with the level of privacy settings they establish. Results from an online descriptive survey of counseling students are compared with and found in many ways to be inconsistent with the literature on the risk factors associated with limited use of privacy settings. Implications of and recommendations for using Facebook for counselors and counselor educators are provided.

Keywords: millennial generation, Generation Y, social networking sites, Facebook, ethics, boundaries

The use of social networking sites (SNS) is increasing in popularity with college students (Hazlett, 2008), and Facebook is one of the most popular sites (Salaway, Nelson, & Ellison, 2008; Fogel & Nehmad, 2009; Hazlett, 2008; Lehavot, Barnett, & Powers, 2010; MacDonald, Sohn, & Ellis, 2010). As of March 2013, Facebook had over 1.11 billion users overall (Facebook, 2013), but the more relevant statistic for this article is the evidence of the site’s widespread use by college students. Data collected in 2006 and 2007 from several studies found that about 60–65% of college students were using Facebook (Fogel & Nehmad, 2009; Lehavot et al., 2010; MacDonald et al., 2010). Recent research conducted on college students found that more than 85% of students who responded to the survey use SNS, and 89% of those who used SNS had a Facebook page (Salaway et al., 2008). Thus, the use of SNS and Facebook is officially part of the college student culture. The fact that so many college students have incorporated Facebook into their lives is highly relevant to the field of counselor education. The majority of students in both masters and doctoral level training programs will have come from this culture, with a strong likelihood that they enter college programs with an existing Facebook page, and anticipate a continued interaction with friends, families and classmates via Facebook. Yet, the use of Facebook raises challenging ethical and clinical issues for both students and counselor educators. These include boundary issues: most importantly, the risks associated with a student’s private information being accessible to clients; issues related to enhancing the integrity of the profession; and the ethical responsibilities of counselor preparation programs in admitting and preparing students for counseling careers. The purpose of this article is to examine the relevant literature on Facebook as it pertains to counselor education, and specifically literature that deepens an understanding of both why students use Facebook and how they use Facebook. Additionally, we will describe the results of a survey of Facebook use at our own master’s in counseling program at California State University, Fullerton (CSUF), which has a large student body, most of whom are members of the millennial generation. The nature of this survey is purely exploratory, with the goal of assessing whether Facebook use in one program supports or challenges the findings in the extant literature. The degree to which those findings are challenged will help clarify the need for and direction of future research. Finally, we will discuss the ethical dilemmas posed by Facebook, make recommendations on how counselor educators can prepare students to use Facebook ethically, and ensure that programmatic use of Facebook maintains the highest ethical standards.

Privacy Settings on Facebook

Before examining the literature, it is important to review the concept of privacy and privacy settings in Facebook, since the way Facebook users deal with privacy is critical to ethically-sound counseling practice. Personal information can be displayed on Facebook including name, address, e-mail, phone number, alma mater (high school and college), current employer and marital status (Facebook, 2013). In addition, questions about spiritual and political beliefs, interests and hobbies can be shared. Finally, the wall, a kind of virtual poster board, offers an opportunity to display any comments one wants to make about a particular topic (such as current events and topics, or a personal story) and has a platform to upload pictures. With each of these primary areas, users can determine whether the public, friends-of-friends, or friends only can see the information. Establishing privacy is usually done at one of these three levels, and Facebook defaults to public; so if a user does not know how to set privacy, most everything will be available for the public to view. This last point is especially salient for counseling students, since their familiarity with the technology of privacy settings directly bears on protecting their boundaries of privacy and keeping clients from accessing personal information.

Why Counseling Students Use Facebook: The Millennial Generation

Within the business profession, the concept of each generation holding its own sets of values is well documented (see Bergman, Fearrington, Davenport, & Bergman, 2011; Howe & Strauss, 2003; Mehdizadeh, 2010; Reith, 2005; Sandfort & Haworth, 2002; Steward & Bernhardt, 2010; Twenge, 2010; Twenge, Campbell, Hoffman, & Lance, 2010). For instance, several comparisons are made between the Silent Generation, baby boomers, Generation Xers, and Millennials comparing work values, school values, and marketing strategies (Twenge, 2010).

A starting point for understanding why the millennial generation of counseling students would be frequent users of Facebook is the role technology has played throughout these students’ development. As Reith (2005) has observed, the millennial generation is more technologically savvy than previous generations. The term researchers used to describe a generation born into the world of current technology is digital natives, as opposed to previous generations, termed digital immigrants, because they developed familiarity with technology as the technology emerged (Prensky, 2001). Additionally, the millennial generation came of age at a time when digital communication was crucial to maintain ties. Reith (2005) observed that many Millennials had parents who involved them in a variety of organized activities, which required highly structured schedules. He proposed that because of limited free time to socialize with friends, perhaps using technology such as texting and social networking provided them with an avenue to informally connect with others in their otherwise busy schedules. Ultimately, the use of SNS and especially Facebook became an integral part of millennial culture (Hazlett, 2008; Salaway et al., 2008).

Howe and Strauss (2003) and Reith (2005) reported that the millennial generation is more conventional than previous generations. They tend to have positive experiences with their parents who enforce rules and, consequently, seem to be trusting of authority and institutions. Perhaps this perception of trusting institutions such as Facebook increases the perception of Millennials that their information is private and safe.

Another possible cultural characteristic is related to the frequent description of Millennials as being narcissistic. One study, using a national sample of 15,000 high school seniors, was able to link narcissism with this generation (Twenge, 2010). Twenge deduced that the experiences of being wanted and therefore feeling special, and of being overprotected and given less responsibility, all may contribute to the higher scores on narcissism by Millennials (Twenge, 2010). Stewart and Bernhardt (2010), after administering the California Psychological Inventories (CPI) to 588 undergraduate students, also found that Millennials scored high on narcissism compared to students from previous generations. They suspected that one possible explanation for these results might be that Millennials are launched into adulthood much later as compared to previous generations. Mehdizadeh (2010) used the Narcissism Personality Inventory (NPI)-16 to assess the level of narcissism of 100 students who were Facebook users at York University. Strong correlations were found between higher scores on narcissism and self-promotional information displayed on the wall. The author asserted that the venue used to post one’s status on Facebook established an acceptable culture of boasting in this forum, which was a criterion used to establish the level of self-promotion.

Thus, the research suggests that Millennials may use Facebook more than previous generations (Hazlett, 2008; Salaway et al., 2008) because of several factors such as the experience of being digital natives; the convenience of connecting with friends through SNS to compensate for busy schedules; trust in institutions; and the correlations found between Millennials and higher scores on narcissism. At the same time, the research is limited, and it would be prudent not to stereotype a generation as narcissistic without more compelling evidence. It also is important to note that the measures used in the above-cited students did not ascribe pathological value to the construct of narcissism, as opposed to how clinicians tend to use the term.

How Millennials use Facebook: The Issue of Privacy Settings

While there is no literature on privacy settings and counseling students or novice counselors, a number of studies have looked at how the millennial generation tends to use privacy settings on Facebook. For the purpose of this article, the most important research involves Millennials involved in health care of some form. MacDonald et al. (2010) looked at the Facebook pages of young doctors in Australia and found that just over a third did not use any privacy options at all. Most of the doctors’ Facebook pages revealed personal information like spiritual or political beliefs, but withheld information such as home address and phone number. Very few of these pages demonstrated inappropriate behaviors such as drinking or using foul language when posting on the wall. However, many doctors had photos that were revealing and perhaps inappropriate for patients to view.

Lehavot et al. (2010) surveyed psychology students and found that about 60% allowed only friends to view their page, while 34% allowed the public to have full access to their Facebook page. The remaining 6% were unsure about privacy settings. Despite the high percentage of users who limited access to friends, they still posted questionable information or photos. When asked, about 3% of respondents had photos and 6% had information that they would not want classmates to see. Those percentages increased when asked about information or photos they did not want faculty (11%) and clients (29%) to see. Taylor, McMinn, Bufford, and Chang (2010) surveyed psychology students and psychologists and found that 85% of those with a Facebook page used at least some level of privacy. However, it is possible that this figure is so high because the sample included licensed psychologists, who may be older than Millennials and more conscientious of potentially crossing boundaries with clients who might gain access.

Other studies, not with health providers, but with Millennials in general, seem to indicate who among this generation would be most likely to disclose personal information; these findings may be relevant to counselor educators if they help identify which students are most likely to need instruction on protecting their Facebook privacy. What the literature suggests is that those individuals who are most likely to allow personal information to be seen are male and people not involved in romantic relationships (Fogel & Nehmad, 2009; Mehdizadeh, 2010; Nosko, Wood, & Molema, 2010; Salaway et al., 2008). The fact that young men tend to use Facebook for self-disclosure may relate to findings in other studies that Facebook disclosure is associated with the trait of risk-taking (Fogel & Nehmad, 2009). The one exception to the finding that men tend to disclose more than women relate to the display of photos, which appears to be a behavior associated with female Millennials (Mehdizadeh, 2010; Salaway et al., 2008).

Consequently, since the research found that about 15%–30% of users in the health professions do not use any privacy settings at all in Facebook, counselors-in-training also may be at risk (Lehavot et al., 2010; MacDonald et al., 2010; Taylor et al., 2010). For individuals who did establish some level of privacy, many men posted information and women posted photos that they would not want clients, professors, or supervisors to see (Fogel & Nehmad, 2009; Lehavot et al., 2010; Mehdizadeh, 2010; Nosko et al., 2010; Salaway et al., 2008). In addition, individuals who posted their relationship status as single seemed to reveal more information, and many Millennials in counseling programs are likely to be single (Nosko et al., 2010). However, no research has been conducted to determine if these results resonate with the counseling profession.

Graduate Student Assessment of Facebook Use

Given the growing awareness of the graduate counseling student population at CSUF and the characteristically large number of students classified as Millennials, we, the authors, wanted to evaluate the level of disclosure with our own sample of students. The purpose of this survey was to evaluate whether millennial students in our graduate program used Facebook more than older generations. Secondly, we wanted to explore the risk factors associated with decreased use of privacy settings, such as being male, single and from the millennial generation as the literature seemed to indicate. Finally, we wanted to assess the impact of discussing the ethical challenges and uses of Facebook in each section of our law and ethics classes on privacy settings given the results obtained from the survey. This survey was meant to provide a descriptive understanding of our students to compare with the extant research.

Social Networking Survey

A brief survey was created based upon questions that arose from the literature regarding usage and privacy settings. The survey was approved by the Institutional Review Board at our university and was organized into four distinct areas that could be easily completed online. These areas included student consent to complete the survey, demographic information, social networking information and Facebook questions. The social networking information dimension asked questions about student involvement in SNS and knowledge about privacy settings. The Facebook questions addressed issues related to one’s profile and the public or private display of personal information.

The online survey was completed at two time intervals: late January 2012 (admin. 1) and early November 2012 (admin. 2). Prior to disseminating the survey in January 2012, the faculty had not yet incorporated any discussion about social networking or Facebook with students. During spring, summer and fall all sections of the law and ethics class included at least some discussion about social networking, using Facebook as an example. Each faculty member presented the information informally and without uniformity. Despite the differences in addressing this area in class with each of the instructors, who also are authors of this paper, the possibility of clients making friend requests on Facebook was presented, and students were encouraged to brainstorm ways in which they might handle this situation.

Participants

Students for this online survey were recruited from approximately 220 current matriculating students in the graduate program in counseling at a public university on the West Coast. They were invited via e-mail to participate, were guaranteed confidentiality, and had no negative consequences for refusing to participate. However, in both administrations they were provided with an incentive in a random drawing to win a $25 gift card from iTunes.

In late January 2012, we obtained 56 responses, and in early November 2012, we received 63 responses (24% and 29% of the students, respectively). In the initial administration, 92.9% of respondents reported using SNS, and 100% of those who used sites participated on Facebook. The second administration indicated that 90.3% of the respondents used SNS with 98.2% of this group participating on Facebook. These results are consistent with the literature about the popularity of Facebook among SNS (Salaway et al., 2008). Primary demographic information on each respective survey is found in Table 1. Note that slightly more than half of the respondents in both administrations were from the millennial generation.

Table 1

Demographic Information

Results

First Administration

The first set of results extrapolated from the survey included a review of risk factors for using few or no privacy settings on Facebook including being male (Fogel & Nehmad, 2009), having a relationship status of single (Nosko et al., 2010), and being from the millennial generation (Nosko et al., 2010). The first survey supported the literature with regard to gender. In our initial survey, 50% of the male students (4 of 8 men) used privacy settings for less than half of their information whereas only 14.6% of the female students (6 of 41 women) used privacy settings for less than half of their information. Regarding photos or videos that students would not want clients to see, 50% of men and women surveyed had such photos or videos. However, nearly all male students (6 out of 7) had information they would not want clients to see; the eighth male student did not specify. In contrast, 50% of female students had information they would not want a client to see.

The trends Nosko et al. (2010) found regarding the relationship between being single and using lower privacy settings did not hold true in our first sample of students. Of the fifteen students who identified as being single on the first survey, only one student did not have the highest levels of privacy established. In contrast, 9 of the 38 students who reported being in a relationship had set less than 50% of their information with some level of privacy. Therefore, in our graduate counseling student population, being single did not seem to correlate with lower levels of established privacy.

Finally, Nosko et al. (2010) found that younger individuals tended to have more information displayed on their Facebook page. When evaluating the reported levels of privacy established by our students in the first survey, this trend did not hold. The majority (86%) of students from the millennial generation reported establishing privacy settings for at least 50% of their information. Students from older generations were slightly less likely to establish privacy for at least 50% of their information. In our sample, 71% reported establishing this level of privacy. Therefore, our data did not support the trends found in the literature for establishing levels of privacy relating to age or relationship status, but we did find that male students seemed to display more information.

Differences Between Administrations

Next, we had a comparison made between the first and second administrations of the survey to determine if teaching about the ethical challenges of using Facebook would impact privacy settings. In the first administration, about 48% reported establishing the maximum privacy allowed, and another 30.8% reported that more than half their information was private. The second administration showed an increase in the maximum privacy allowed at 63.2%. Another 26.3% of students reported having over half their information private. These results indicated an increase in privacy settings from the first to the second administration.

We wanted to explore some possible explanations for this change. First, we had a third party compare the two lists of names and found that 11 students completed the survey a second time: seven already had the highest level of privacy set in the first survey and did not change their settings; three increased their level of privacy; and one did not have the highest level and did not increase the level of privacy. Some students made comments in the first survey stating that participating in the survey made them more aware of privacy settings, and consequently they wanted to establish more rigorous privacy settings; it appears that three students did, in fact, make this change. These results imply that at least part of the increase may have simply been due to completing the initial survey. Next, we had a third party review the names of all students who were currently in or had taken the ethics course between the two administration times. The results indicated that 10 students who took the second survey had completed an ethics course between administrations, and we know that during this time all instructors who taught ethics discussed the ethical challenges of using Facebook. In reviewing the results of the second administration, we found six had established the highest level of privacy; two had 50% or more of their information set as private; and two had less than 50% of their information set as private despite having been exposed to the risks associated with limited privacy. We hope that these students are simply less active users of Facebook and therefore do not feel the need to establish more rigorous settings, but we do not know for certain.

Several articles noted that a few individuals seem to establish some privacy settings, but still had photos that can be seen by the public (Lehavot et al., 2010; MacDonald et al., 2010; Salaway et al., 2008). Much like the rigor of privacy settings, the results of photos displayed to the public shifted between each administration (see Table 2).

Table 2

Photo Visibility Privacy Level on Facebook

Lehavot et al. (2010) found that 3% of respondents had photos and 6% had information they would not want their classmates to see. These numbers increased when asked about faculty (11%) and clients (29%). Our results showed this same trend with both administrations of the survey. Table 3 shows the trend for pictures or videos that students would not want classmates, professors, supervisors or clients to see. Table 4 reveals a similar trend about information posted that students would not want others to see. These trends did not change substantially between administrations as we had hoped. We suspect that even though some students increased their levels of privacy, they did not remove information or photos assuming that the improved privacy settings would protect them. This may be explained by the assertion from Howe and Strauss (2003) and Reith (2005), who believe the millennial generation is more trusting of institutions since they had positive experiences with their parents.

Table 3

Picture and Video Visibility Privacy Level

Table 4

Information Posted Privacy Level

We wanted to examine the implications for the current generation of counseling students, as well as for counselor educators on the use of SNS, and specifically Facebook. The potential ethical minefields Facebook presents for students at every level of counselor development persuaded us that both a perusal of the literature and a survey of our own students’ Facebook use would yield important information. In particular, we looked at the prevalence of Facebook use, its possible roots in the culture of Millennials, and the extent to which Millennials expose their private lives on this particular SNS. The results of our two surveys helped us understand Facebook use in our own program, informing us as faculty about retooling ethics education for our students. The surveys also lent support to previous research findings in some areas and raised questions regarding the generalizability of others. However, our survey results are only descriptive and may not be representative of all of our students or of counseling students across the country.

Facebook Risks for Counselors-in-Training

Millennials are the most prolific generation of users of social networking sites (Hazlett, 2008) and therefore, compared to previous generations, have been found in the literature to be more likely to have posted personal information on a SNS. Our data did not support this assertion; the reasons for this phenomenon remain unclear and require further research. It has been suggested that this generation is particularly self-absorbed, and there is some empirical evidence supporting this notion (Mehdizadeh, 2010; Steward & Bernhardt, 2010; and Twenge, 2010), but a less pathologically-tinged explanation may be that self-disclosure on Facebook and other SNS is a cultural norm for them. Regardless, the critical issue is the extent to which counseling students are employing Facebook privacy settings. If, indeed, Millennials tend to use fewer privacy options and are likely to post more information on the wall as compared to other generations (Nosko et al., 2010), their increased use of SNS places this group at a higher risk for crossing boundaries between their personal and professional lives as they enter the counseling profession (Allen & Roberts, 2011). Our survey of students supported the concern that counseling students had created boundary issues for themselves with Facebook use previous to entering the program, and continued to place themselves at risk for further crossings while in the program. Over 90% of our students who responded to our survey used Facebook, and over half had posted information they would not want clients to see. It should be noted that almost half of the students in our first sample and a somewhat higher percentage in the second survey had established maximum levels of Facebook privacy. But that still meant a significant number of our counseling students had recently posted photos, videos and personal information that might compromise a professional relationship if clients were to discover them, and many of these students were using less than maximum privacy settings. Even those using maximum settings continued to post revealing personal information, but with the expectation that no client could access it.

In fact, even with the use of privacy options, counseling students may not be aware of the challenges of controlling access to their Facebook content. Privacy settings do not guarantee that information will remain private. For instance, when using the friend-of-a-friend level of privacy, it is possible that students have unknown common acquaintances with professors or clients; this might inadvertently give a client or faculty access to their information. Consequently, the unintentional dissemination of information remains a possibility and an ethical dilemma. Furthermore, Facebook friends may not use privacy settings, and they may pull an inappropriate picture from a user’s wall and “tag” it, making it available for clients or faculty to view. Consequently, the unintentional dissemination of information remains both a possibility and an ethical dilemma, and requires further study to have a clearer understanding of these risks.

What are the actual ethical consequences raised by Facebook use? Initially, potential damage to clients if they discover revealing information about their counselors could be a serious risk. The credibility of the counselor can be impaired, clients may become tantalized by the counselors’ personal life, and the counselor’s often challenging efforts to maintain clinically helpful boundaries in sessions may be compromised. For psychologically fragile clients who need to temporarily perceive their counselors as authority figures while they recover and develop new coping skills, the discovery of their counselors’ private life might undermine their recovery.

A related issue, as described in The American Counseling Association’s code of ethics, is the counselor’s ethical role in making a distinction between one’s roles personally and professionally (ACA, 2005). Using SNS is where the line between one’s professional world and private world could mingle (Birky & Collins, 2011). Judd and Johnston (2012), addressing related issues for social work training programs, make observations that seem equally relevant to the counseling profession. For example, they note the importance of impression management and the development of an identity that reflects a level of professional dignity consonant with the mission and ethics codes of the particular mental health discipline. When personal information such as a student’s romantic life or photographs of a student in informal situations becomes available, dignity can be compromised, affecting not only the student-counselor, but the profession itself. If that material is seen by a client, the counseling relationship may be damaged, and if seen by a fieldwork agency clinical director or potential employer, the student risks losing a work opportunity.

Myers, Endres, Ruddy, and Zelikovsky (2012) noted an additional concern when they raised the issue of what happens when a client may want to befriend the counselor on Facebook. Agreeing to the request may expose the counselor’s private life, while refusing the request risks wounding the client. In either case, handling the issue requires careful ethical decision-making and skilled intervention with the client. Perhaps one of the most troubling risks associated with self-disclosure on Facebook or other SNS is the increased risk of counselors-in-training being stalked by psychologically disturbed clients (MacDonald et al., 2010). These potential boundary consequences are assertions, though, and merit the need for further research.

Some have argued that Facebook boundary crossings could be therapeutic and appropriate under the right circumstances. Taylor et al. (2010) asserted that younger clients and professional counselors may believe that the use of SNS is an appropriate method of communication or even a therapeutic tool. The millennial generation and perhaps even the current zeitgeist values transparency more than ever before (as seen on television shows such as Oprah or Dr. Phil), which intentionally blurs the boundaries between personal and professional roles in the interest of a more authentic relationship (Zur, Williams, Lehavot, & Knapp, 2009). Birky and Collins (2011) considered context when using SNS between counselor and client. They suggested that the use of SNS might be appropriate under certain circumstances such as theoretical orientation, length of relationship, and both the client’s and counselor’s culture. Nevertheless, while there might be therapeutically valuable uses of SNS in some cases, the risks of Facebook exposure resulting in negative consequences for both counseling students and clients may be high.

Facebook Risks with Admissions and Advising

Prospective and current counseling students may not realize their risks of participating on SNS (Harris & Younggren, 2011) with regard to their education and training. Lehavot (2009) published an article exploring the ethical use of doing Internet searches by faculty members in admissions and advising capacities. Many individuals reported a belief that their blogs or what they posted on SNS was private (Lehavot, 2009). However, Lehavot (2009) argued that in some ways, the Internet is seen as a public domain; therefore, providing an informed consent to prospective students or students entering into a counseling program may be a way to ameliorate the perception by students that this information is private. Even with informed consent, there may be complications. Faculty members may risk discovering information that negatively biases them if they conducted Internet searches on problem students. Students may feel betrayed by this course of action, and documentation could be complicated if they would need to be counseled out of the program. Finally, Lehavot (2009) asserted that completing Internet searches may inadvertently be discriminatory because not all students have equal access. In the admissions process, for instance, one student may have significant positive information on the Internet, while another does not because of lack of resources, despite having similar accomplishments. In contrast, one student may have made a poor judgment in which a photo was taken and subsequently posted online unbeknownst to him or her, while another student may not have had the misfortune of a photo being posted despite making the same poor decisions. Prospective and current students may not consider how much information could be available to faculty or others when using SNS, which could be problematic. More research is needed to assess the desire of counselor education programs seeking to utilize Internet searches for admissions and advising and how this might impact the admissions and advising process.

Recommendations

To recommend that one avoid the use of Facebook or SNS in general would certainly eliminate any ethical hazards of boundary crossings in counseling, supervision and counselor education. However, this solution is unrealistic, if not impossible. SNS are increasingly becoming embedded in the culture as a way to connect with others, both near and far (Reith, 2005). Therefore, the counseling field should aspire to identify methods to reduce rather than eliminate risks associated with using Facebook. Since the Internet is an integral part of students’ and faculty members’ lives, discussing the impact of using Facebook or other SNS is imperative (Lehavot, 2009). Students should be informed as soon as they begin the program about how social networking culture tends to blur personal, social and professional boundaries. Consequently, counseling students should be made aware of the impact that using Facebook could have on socializing with each other and on the development of professional behavior, especially as they begin seeing clients. Students also can be advised to do an Internet search on their own name to discover what personal information is available online to clients (Zur et al., 2009).

Counselor educators can encourage students to make better decisions about their use of Facebook. For instance, privacy settings on Facebook are dynamic and have become increasingly complex. Students should become educated about this complexity and the risks associated with each level. Students should be aware of risky behavior online, such as publishing photos of themselves in compromising situations. In addition, students should refrain from making inappropriate YouTube videos or communicating in ways that display unprofessional behavior. Counseling students should be advised to maintain all client discussions or references of client information within a context of face-to-face clinical supervision meetings, meetings with peer counselors, or prescribed dialogues with faculty members, and should not reference anything related to clients on Facebook. Furthermore, communicating with clients on Facebook, or any other social media outlet, should be discouraged in most cases; professional boundaries can be too easily crossed.

One encouraging implication that emerged from the administration of both surveys in our graduate counseling program was that it might be fairly easy to change students’ attitudes about Facebook privacy. Discussion of Facebook issues in an ethics class that occurred between the two surveys may explain why more students were using maximum privacy settings in the second administration sample. It also is possible that some students increased their privacy as a result of having participated in the first administration, suggesting that just making students aware of these issues impacts their Facebook practices. Students in the second administration increased privacy levels for photos, videos and information. Moreover, their primary goal was in preventing access by clients, suggesting their chief concern was in accordance of the ethical principle of “do no harm.” Further research is needed to determine how much exposure to Facebook issues, both ethical and technological, is necessary to help students ensure maximum privacy protection. Introducing discussion into a program’s ethics class and, as noted above, addressing the issue at the beginning of the program, would seem to be natural methods for achieving this goal. However, graduate counseling program leaders may choose a variety of learning experiences to help students deal with the Facebook privacy dilemmas, including ethics classes, introductory courses, practicums or special workshops, or they may infuse options throughout the curriculum.

One way to start enhancing student self-awareness is by exploring the meaning of transparency and how this language may be interpreted among the millennial generation as compared with other generations. Dialogues about the levels of self-disclosure revealed on Facebook as compared with face-to-face interactions could enhance students’ awareness. Students can brainstorm potential dilemmas that may emerge when participating on Facebook that may cross boundaries with other students, faculty or clients. Developing a proactive strategy when private information becomes unfortunately disclosed is another important topic to discuss with counseling students to enhance awareness. As Levahot (2009) has noted, the discovery by a student trainee that a client has accessed the trainee’s personal information can lead to a therapeutically valuable conversation with the client during treatment.

Counseling program leaders should carefully evaluate and establish a policy about investigating clients on Facebook without their informed consent. Viewing this information can place counseling students in very difficult dilemmas about appropriate professional behavior, particularly if a search reveals the potential or expectation of clients to cause harm to self or others. Students should be advised to remain up-to-date with emerging technologies their clients may use.

Counselor educators should be literate about Facebook and other technological advances that students may be using. Students are often more competent in these areas, and learning about how students engage on Facebook may open more productive communication about how to maintain appropriate professional boundaries. Counselor education program leaders have an additional responsibility of training agency supervisors on the potential benefits and risks of using SNS. Lehavot et al. (2010) and Taylor et al. (2010) noted that if supervisors seem dated and technologically challenged to supervisees, then supervisees will be less inclined to bring up the conversation when challenges arise. Consequently, supervisees may make poor decisions leading to unintentional boundary crossings with clients. Therefore, it is critical for supervisors to also be prepared to initiate a conversation about the use of Facebook.

Finally, counselor educator program leaders should develop policies regarding investigation of students’ Facebook pages by instructors, supervisors and admissions committees. Instructors and supervisors should initiate conversations with students about mutually participating on SNS such as Facebook. SNS sharing may lead to inappropriate disclosures of personal information that could compromise the faculty-student or supervisor-supervisee relationship. If admission committees intend to look at applicants’ Facebook pages, this policy must be included in departmental Web pages and printed materials describing admissions criteria. The most desirable approach is probably that admissions committees should refrain from using the Internet in general to examine a student’s fitness for a program.

The use of SNS has increased in the last three years, even among the baby-boom generation and Generation X (Hazlett, 2008). Counselor educators have an opportunity and responsibility to become familiar with this technology to protect counselors-in-training and the clients they serve. Additional research should be conducted on the current use of both SNS and privacy settings by counseling students. Our survey suggested that most of our millennial generation counseling students used Facebook; posted photos, videos and information they would not want clients to see; used various levels of privacy settings; and readily increased their privacy settings once exposed to information about Facebook risks. However, this was preliminary information with two small samples; more thorough research is needed in assessing the extent of Facebook use among counseling students, their familiarity and use of privacy settings, and best practices for teaching appropriate use of Facebook for counselors. In addition, determining the types of students who are less likely to establish appropriate privacy settings could be evaluated in order to target those students and reduce negative outcomes. Research could be conducted to evaluate the efficacy and inherent risks of using SNS in counselor education programs and in counseling as well.

Though the basic foundation of counseling has not changed drastically in recent years, current technologies have the potential to enhance or diminish therapy. The setting of counselor education programs is an excellent environment to explore benefits and risks associated with integrating new technologies. By doing so, counselors can remain informed about evolving technology to enhance their work with clients.

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Leah Brew, NCC, is Chair and Associate Professor in the Department of Counseling at California State University, Fullerton (CSUF). Joseph M. Cervantes is a Professor and David Shepard is an Associate Professor, both in the Department of Counseling at CSUF. Correspondence can be addressed to Leah Brew, Department of Counseling, P.O. Box 6868, Fullerton, CA 92834-6868, lbrew@fullerton.edu.

A Therapeutic Approach for Treating Chronic Illness and Disability Among College Students

Oct 15, 2014 | Article, Volume 3 - Issue 3

Katie L. Haemmelmann, Mary-Catherine McClain

Research in chronic illness and disability (CID) in college students has demonstrated that students with disabilities encounter more difficulties psychosocially than their nondisabled counterparts. Subsequently, these difficulties impact the ability of these students to successfully adapt. Using the illness intrusiveness model in combination with cognitive behavioral therapy (CBT), the authors propose therapeutic interventions that could be taken with these students to enhance their overall well-being, adaptation and academic success. The authors also provide final thoughts with directions for future research and application.

Keywords: chronic illness, disability, illness intrusiveness model, cognitive behavioral therapy, college students with disabilities

Chronic illness and disability (CID) impact more than 35 million Americans, often interfering with their everyday life (Livneh & Antonak, 1997). The condition is typically accompanied by a prolonged course of treatment, an often uncertain prognosis, constant and intense psychosocial stress, increasing interference with the performance of daily activities and life roles, and conflict with family and friends (Livneh & Antonak, 1997). Approximately 11% of undergraduate students reported having a disability in 2008 (National Center for Education Statistics, 2011) and 88% of colleges are continuing to enroll students with disabilities (The Princeton Review, 2011). In addition to adjusting to the presence of a disability, adjustment to independent living and beginning academic courses at an undergraduate institution can be challenging for someone with a chronic illness or disability.

The severity of the disability and its functional limitations do not always correlate in a uniform pattern with coping and adjustment (Lustig, Rosenthal, Strauser, & Haynes, 2000). Similarly, disability may include permanent and significant changes in an individual’s body appearance, functional capacities, body image and self-concept (Lustig et al., 2000). This variable, typically referred to as psychosocial adaptation, becomes compounded among college students and deserves further investigation. In order to better understand the adaptation process, conceptualize cases, and provide the most effective services to college students with disabilities, it is important for researchers to test comprehensive models specifically designed to aid in the interpretation of illness-induced interference. Similarly, counselors need to understand and implement empirically supported interventions, techniques and related strategies to assist individuals with disabilities in the transition to higher education.

Currently, there is a dearth of information pertaining to the adjustment of young people that can be applied to college students with chronic illness and disabilities. Additionally, theories within the rehabilitation, quality of life, and counseling literature are used to translate theory into practice. After describing the nature of transitions individuals face upon entering college, discussing current legislative policies, and examining identity formation, this article provides an overview of the illness intrusiveness model and theoretical framework for CBT. Next, the article offers strategies for implementing an integrated model, including elements of illness intrusiveness and CBT, with the college population. Treatment strategies and intervention techniques are also described. Finally, accommodations, the importance of social support, and future directions are addressed.

Identity Formation and College Transition

     Identity formation typically continues during the late teens and early 20s (Luyckx, Schwartz, Soenens, Vansteenkiste, & Goossens, 2010), which also is the time when youth attend or transition to higher education. During this time, the individual is still a child on one hand, yet an adult on the other hand. According to Wright (1983), this creates an overlapping situation in which the adolescent with the disability is not only struggling with the problematic overlap of “child” and “adult,” but also that of “normal” and “disabled.” This is a complex time filled with instability and uncertainty regarding the years ahead. A synthesized sense of identity can provide beneficial effects on an individual’s adjustment (Luyckx et al., 2010), and a comprehensive sense of self can be facilitated through psychotherapeutic interventions. Also, the process of adaptation is multidimensional, complex and subjective (Smart, 2001). Consequently, a comprehensive framework for assessing and intervening is critical for fostering positive counseling outcomes.

Preparing someone for a career is a task that should not be taken lightly, but given the utmost attention. Career can be defined as the “time extended working out of a purposeful life pattern through work undertaken by the person” (Sampson, Reardon, Peterson, & Lenz, 2004, p. 6).This definition helps clarify the idea that a career is an activity people engage in regularly through a lifetime. Employment opportunities for this population are already limited by job choice (variability), available hours, and reduced salary (Schmidt & Smith, 2007). Also, enhancing potential job opportunities for individuals with disabilities is beneficial, as research has shown that the onset of a disability can negatively influence one’s vocational identity—potentially leading to poor adjustment, limited self-direction and goal setting, and lower career development (Enright, Conyers, & Szymanski, 1996; Skorikov & Vondracek, 2007; Yanchak, Lease, & Strauser, 2005).

According to Kirsh et al. (2009), with the economy becoming increasingly knowledge-based, and as the forces of globalization transform to eliminate entry-level positions, people with limitations in cognitive function may become increasingly marginalized. This is not to say that this population can maintain only entry-level positions, but to reiterate that as there is an increase in students with disabilities attending universities, there is an increase in job requirements, qualifications and performance levels required by all populations. Enhancing education and overall college experience with counseling will assist these students as they acquire new skills to use for the rest of their lives.

Need for Psychotherapeutic Interventions

In the past 20 years, there has been a trend of more persons with disabilities pursing higher education. Based on the National Organization on Disability Harris Survey of Americans with Disabilities conducted in 2000, there was a marked increase in persons with disabilities having graduated from high school (77%) compared to those in 1986 (61%). Based on several legislative and social policies implemented in the 1980s (Canadian Human Rights Act, 1985) and 1990s (Individuals with Disabilities Education Act, 1997 [IDEA]), an estimated 8–18% of students in higher education are students with disabilities (Sachs & Schreuer, 2011). Furthermore, persons with disabilities entering postsecondary education are making significant progress toward successful completion of their program of studies (Stodden & Whelley, 2004). This is why educators, administrators, and policymakers are working to improve services while also providing accommodations, interventions, and support services in postsecondary settings (Barazandeh, 2005; Brinckerhoff, Shaw, & McGuire, 1992; Dowrick, Anderson, Heyer, & Acosta, 2005;  Dutta, Kundu, & Schiro-Geist, 2009; Johnson, 2006; Swanson & Hoskyn, 1998; West et al., 1993). Examples of such accommodations include transportation, separate locations for test taking, access to private study rooms, and extended time on exams.

With the reauthorization of the IDEA in 1997 (PL 94-142), there was an increase of higher expectations upon quality preparation to postsecondary education and employment for persons with intellectual disabilities. The Americans with Disabilities Act (ADA) sought to provide reasonable accommodations to ensure equal access to learning and work environments (Jacob & Hartshorne, 2007). The vocational rehabilitation system exists to provide assistance to individuals with disabilities seeking employment. This can be a good support system for those interested in higher education, but only supports eligible consumers (Gilmore & Bose, 2005). While these recent pieces of legislation have been incredibly beneficial and have encouraged individuals and professionals alike to actively engage in advocacy, they do not specifically address the access or right to counseling as an appropriate accommodation.

As students transition to postsecondary education, fear of the unknown affects not only those transitioning, but the people around them (e.g., professors, administrators or counselors) as they experience a change in roles. Parents, for instance, may want to protect their child from the risks of the larger world, and limit them by choosing self-contained and protected programs (Stodden & Whelley, 2004). This approach may deprive students of the opportunity for further education. With optional counseling specifically designed for those individuals with disabilities transitioning into the next phase of life, this may be reassuring not only for the student, but also for the student’s primary support system. One counseling model to implement in such situations is the illness intrusiveness model.

Illness Intrusiveness Model: Theoretical Framework

The illness intrusiveness model was developed based on the idea that illness-induced interference, in addition to interests and valued activities, compromises one’s psychological well-being—ultimately contributing to emotional distress. It is derived from a variety of sources such as functional losses, treatment side effects, disease and treatment-related lifestyle disruptions, and disease-related anatomical changes (Devins, 2010). The model postulates that when there is a decrease in positively reinforcing outcomes from valued activities and limited personal control (e.g., mood level) to obtain positive outcomes and avoid negative ones, significant adaptive changes and coping demands occur (Devins, 2010).

By examining the five factors of disease—that is (1) treatment requirements, (2) personal control, (3) nature of life outcomes, (4) psychological factors, and (5) social factors—one can inspect the level of participation in valued activities, also known as illness intrusiveness. Illness intrusiveness may serve or act as a mediating variable by which unbiased circumstances of disease and treatment influence psychosocial well-being and emotional distress. Specifically, illness intrusiveness is based not only on the experience of the person, but also the psychological characteristics based on objective and subjective concepts (Roessler, 2004).

This model posits that social and psychological factors have a direct effect on life outcomes. Time spent transitioning into college is heavily influenced by social factors, which can create positive or negative experiences in the individual. If the social factors weigh heavily on the individual’s psychological factors in a maladaptive way, the person’s coping abilities and adaptation skills may be compromised and lead to undesirable outcomes. The model also encompasses the idea of locus of control, presented as personal control of self-efficacy (similar to what was described earlier in this article), the idea being that low levels of personal control result in learned helplessness (Roessler, 2004). Furthermore, the theoretical framework hypothesizes that intrusiveness mediates the psychosocial effect of chronic conditions. Indirectly through the effects on intrusiveness, illness and treatment variables are believed to impact subjective well-being (Bettazzonie, Zipursky, Friedland, & Devins, 2008). Incorporation of the illness intrusiveness model can assist professional counselors and clients alike in laying out a clear path of focus (i.e., the five factors of disease; Roessler, 2004) while simultaneously increasing one’s coping and adaptation skills, as well as external allocation of self-efficacy. After describing an assessment tool and following a review of ways in which the illness intrusiveness model has been applied to specific illnesses and populations, the authors provide a rationale for implementing this model among college students with disabilities.

Application of the Illness Intrusiveness Model

Previous research suggests that applying various components of the illness intrusiveness model (e.g., examination of domains) in end-of-stage renal disease clients is effective in objectively measuring varying modes of treatment (e.g., transplantation, dialysis; Devins, et al., 1983). Furthermore, the levels of illness intrusiveness directly affected the psychosocial impact of the condition. Additionally, it was noted that severity levels of hyperhidrosis shared a significant positive correlation with scores on the Illness Intrusiveness Rating Scale (IIRS) (Devins et al., 1983). Intrusiveness scores were weakly related to efforts to control the condition (i.e., medications and ointments), which is indicative of the value of knowledge of self-care techniques and action-based knowledge (Roessler, 2004). Empirical support also has pointed to illness intrusiveness as a precipitant for depression and for feeling a loss of control. This has been observed in persons with arthritis, cancer, diabetes and multiple sclerosis (Roessler, 2004). Furthermore, Devins (2010) notes that levels of illness intrusiveness vary according to illness severity, and weigh in differently for valued activities. This is of particular importance when collaborating therapeutically with college students with disabilities, since there are a wide range of disabilities (e.g., learning disabilities, physical disabilities, mental illness) and they vary in severity (e.g., psychiatric symptoms, functional ability). Subsequently, even among college students with disabilities, there is a wide array of differences; one would expect a shift in valued activities based on transitioning (e.g., social support, school involvement) and disability interference.

The illness intrusiveness model is ideal for working with college students with disabilities because it focuses on improving psychosocial adaptation outcomes. Specifically, it stresses the effect of psychological, social and environmental variables on the interpretation of the disease (Roessler, 2004). This is essential knowledge for implementing effective therapeutic interventions for this population, because often the transition into the college atmosphere impacts the interpretation of the individual and the disability. Additionally, the theoretical framework helps to estimate the effect of disease interpretation and the intrusiveness of treatment factors (Roessler, 2004).

As mentioned previously, the college student population typically struggles to form self-identity in terms of a developmental framework, and intrusiveness is presented in this model as both an objective and subjective concept. This is noteworthy since these individuals are still processing their identity, their life goals, and their viewpoints. With a helping professional, they can work collaboratively to change perspectives that may be distorted or need reframing. Finally, the illness intrusiveness model implies that intrusiveness has a direct effect on both personal control and life outcomes (Roessler, 2004). Through prevention or early intervention, college students with disabilities will realize and begin to feel empowered as they recognize their ability to take control of their lives. This can further be reinforced by seeing positive outcomes almost immediately when collaborating with the practitioner. Before discussing how the illness intrusiveness model can be integrated with other treatment approaches and how it can be applied to college students with disabilities, it is useful to provide a brief history of general psychotherapy with disabled persons and core principles of CBT with this population.

History of Counseling with Persons with Disabilities

Over the past several decades, four basic approaches to adjustment services (e.g., work acclimation) have emerged in disability literature. While the approaches are not mutually exclusive, each offers a new viewpoint on adjustment for persons with disabilities and sheds perspective on both the client and practitioner.

The work acclimation approach utilizes the psychological principle that the greater degree to which a current environment resembles a future environment, the more likely an individual would behave in the same manner in the future environmental setting. Programs utilized almost exclusively in work centers were pay incentives, peer and supervisory work pressure, production rate feedback, lead workers, and status-promotion incentives.

The problem-solving approach to adjustment services represents the second model. It begins by obtaining baseline measures of the problem and delineates adjustment services to any treatment and training modalities necessary to ameliorate the problem, thus allowing the student to succeed academically and vocationally. It is within this model that the approach employs behavioral counseling and behavioral modification techniques that can be applied in multiple settings or situations (Couch, 1984). For example, in a university setting, students with disabilities can be seen for brief or extended psychological services, in which baseline and outcome data are used to encourage behavioral modification and monitor intrusiveness.

In the developmental approach, clients are viewed as capable, problem-solving individuals, fully qualified to accept responsibility for life and determine personal direction. They are taught self-responsibility and self-potency, as well as beliefs, values, and skills, all of which will enable them to solve problems, maintain a sense of self-worth, and enhance personal identity.

Finally, the education approach takes on a different perspective and focuses on skill deficits. This helps the client to engage in remedial education, learn about available resources, and conquer tasks. Examples of such tasks include acquiring a driver’s license or earning a college degree (Couch, 1984). A focus on skill deficits blends well with the theoretical origins of CBT. The following section briefly describes the framework of CBT.

Theoretical Framework for CBT

Three main goals set forth in the field of rehabilitation counseling pertain to affective goals, cognitive goals, and behavioral goals (Parker, Szymanski, & Patterson, 2005). This is similar to taking a holistic or ecological approach in the field of counseling. It is important to treat not just specific aspects of individuals, but to treat the individuals as humans in their entirety. Thus, when addressing college students with disabilities, it could be important to integrate the illness intrusiveness model with that of CBT. The model itself enables the counselor to apply cognitive and behavioral interventions in order to reduce illness intrusiveness strategically, which could encourage the client to participate in valued activities, redefine personal goals, and restructure irrational beliefs related to intrusiveness (Roessler, 2004).

Furthermore, the counselor is able to provide knowledge of self-management and self-care skills, which is facilitated by task-focused coping and problem-solving skills, both of which are central constructs from CBT and can lead to a positive impact on illness intrusiveness. Finally, by including personal control or self-efficacy as critical variables in the illness intrusiveness model, and as a way to better understand life outcomes, individuals are supported in impacting their perceived self-control on life outcomes related to educational achievement and overall well-being (Roessler, 2004).

Integrating the Illness Intrusiveness Model and CBT

Prior to discussing techniques and skills that can be utilized within this framework and among this population, the present article discusses the importance of incorporating specific concepts or tasks within the realm of a client’s goals. Examining client outcomes of counseling interventions is necessary in the field of mental health and other related fields to acquire knowledge on effective treatments, obtain financial funds, establish accountability, and achieve long-term positive results. In addition to cognitive behavioral techniques, client variables with this population may impact the outcome of therapy. For example, Ju (1982) discovered that clients having 12 years of education do not seem to benefit from receiving information and exploring feelings. Rather, they tend to benefit from counselors who predominantly listen attentively and focus on the facilitation of client expression and concern. Additionally, clients with more than 12 years of education tend to reap the most benefits from counselors who not only emphasize the processing of information, but also share personal values, opinions and experiences with the client. This has potential treatment implications from the start of counseling, because to be a viable candidate for collegiate studies, the individual has to successfully complete 12 years of prior education (either formally or in an alternative manner). As students attending school will always vary widely in age, this factor should be kept in the forefront of the counselor’s mind.

Rehabilitation counseling has a history of being goal directed and behaviorally oriented as opposed to a psychodynamically oriented treatment (Ju, 1982). Similarly, a defining characteristic of CBT is the proposal that symptoms and dysfunctional behaviors are often cognitively mediated; thus, modifying dysfunctional thinking and beliefs can lead to improvement (Butler, Chapman, Forman, & Beck, 2006). By following a psychoeducational model, emphasizing therapy as a learning process that includes acquiring and practicing new skills, learning new ways of thinking, and obtaining more effective ways of coping (Corey, 2005), students with disabilities can benefit from improved adjustment to the college atmosphere.

A central role in CBT is the treatment rationale, which provides clients and counselors with a model of etiology and treatment (Addis & Carpenter, 2000). It is within this framework that the counselor teaches the client to identify, evaluate and change dysfunctional thinking patterns so therapeutic changes in mood and behavior can occur (Padesky & Greenberger, 1995). Additionally, it is imperative to address an individual’s metacognitions, or understanding of self-knowledge, in order to grasp the process of cognition and its outcomes (Hresko & Reid, 1988).

Thomas and Parker (1984) remark on the need for effective counseling with persons with disabilities, identifying the following two main focuses: career and psychosocial issues. This only reiterates the need for therapeutic intervention for this specific population who is trying to further education in order to obtain chosen careers while simultaneously adapting to a new lifestyle and appropriately managing the disabilities. It is by weaving together the major tenets presented in CBT (e.g., thoughts, moods, behaviors, biology, and environment; Padesky & Greenberger, 1995), with the five factors of disease (Roessler, 2004) in the illness intrusiveness model that practitioners will be better able to serve this population. This is not to say that all ten areas will need to be remedied or addressed for each individual seeking treatment. Rather, counselors need to be aware that each individual will have different needs to meet or areas to improve.

Akridge (1981) stated that psychological adjustment is an ongoing process of evaluating the self-in-situation to adaptation. A comprehensive self-assessment in the psychosocial domain is the process of summarizing one’s satisfactions and dissatisfactions within the self and the personally relevant aspects of one’s situation. This could be undertaken within the realm of the therapeutic alliance as the client and counselor are working collaboratively toward agreed-upon goals and a focus on improvement. One could suggest the completion of a prescribed homework assignment addressing the area needing further investigation. The client could then experience an increase in self-confidence through exploring each domain, thus decreasing the impact of intrusiveness.

To begin treatment successfully, the counselor and client need to establish a positive, collaborative working relationship. Aaron Beck emphasized the quality of the therapeutic relationship as basic to the application of cognitive therapy (Corey, 2005). The core therapeutic conditions described by Carl Rogers in his person-centered approach are viewed by cognitive therapists as being necessary, but not sufficient, in producing optimal therapeutic effects (Corey, 2005).

The collaborative relationship is essential because it conveys to clients that they possess important information that must be shared to solve problems. Counselors employ general strategies and treatment models while clients are keepers of all the information about unique experiences—only clients can describe thoughts and moods (Padesky & Greenberger, 1995). This again enables clients to build self-esteem and feelings of self-worth so they begin to feel confident in skills and abilities in areas they may doubt. This in turn impacts the domains of career choice, personal control, life outcomes, and psychological and social factors.

In order to be successful at the collegiate level, one must possess sufficient organizational skills. When working with students with disabilities, it is important to address this topic and readdress it throughout the psychotherapeutic process. This approach is key to assist clients in learning to control the things they can in regards to homework assignments, readings, and note-taking, so that if something unexpected or overwhelming becomes more pertinent in unpreventable circumstances, clients will be able to recognize that they have done what they can to contain circumstances within their personal control.

This also relates back to the topic of increasing awareness of metacognition and the cognitive processes. For example, a student may begin to recognize trouble learning a particular topic or realize that there is a need to double-check written work. Similarly, a student may know to review all potential answers before choosing one as the correct option and understand the need to write a task down in order to remember it—essentially working to improve study skills (Hresko & Reid, 1988). Another concept or task that needs to be addressed with this population is that of appropriate accommodations within the university.

Accommodations

The Americans with Disabilities Act states that a disability is “a physical or mental impairment that substantially limits the individual in one or more major life activities” (Jacob & Hartshorne, 2007, p. 209). In such instances, in order for the students to receive and begin using the resources available within the setting and circumstances of the disability, they most likely will need to provide appropriate documentation. This may be an instance in which the therapist needs to take on a more pragmatic role and point the students to the designated resources so they can begin partaking in services. In addition, this simple task models advocacy for the individual. Once the client has taken the required steps to establish services, the practitioner will need to discuss with the client what kinds of services or accommodations may be needed, not only in the classroom, but also for transportation, living, studying, or choosing a career path. A client may need extra time taking tests, to meet with a class note-taker, or require special transportation or access within living space. Addressing organizational skills, as stated previously, may be a way to lead into the topic of study habits or assistance required in completing homework. Clients with mobility limitations or attention deficits may need instruction in specialized computer programs when required to write their thoughts on paper.

Altering Social Factors

Another task or concept that could be discussed within the counseling sessions is social support outside of the therapeutic alliance. Counselors should discuss with the client what types of support have been used in the past, what has worked, what did not work, and what could be modified. In some cases, clients may rely solely on their family for social support while others may rely on both family and friends. It would be beneficial to discuss the client’s preferred approach, to lay out the necessary steps, and to discuss the practicality of accomplishing the support. Some students may find it helpful to join various clubs or organizations, while others may wish to take part in a support group for persons with disabilities who are experiencing similar struggles. One option may be attending a counseling group offered at a university counseling center in which aspects of CBT and illness intrusiveness are addressed. Regardless of the outlet clients require to reach the most beneficial level of social support, they need a realistic understanding of the work required to reach the goal, a picture of what that process looks like, and a comprehensive understanding of why a good support system is necessary. This process will most likely be an ongoing learning experience for both the counselor and client as appropriate adjustments are made and learning and growth are facilitated.

Corey (2005) stated that the goal of CBT is to challenge the client to confront faulty beliefs with contradictory evidence that is gathered and can be evaluated (e.g., thought record). Another important aspect of CBT is goal setting. Padesky and Greenberger (1995) identified five key points about the importance of goal setting. First, setting goals helps identify what clients want to change, and provides guideposts to track progress. Charting such changes within the realm of the illness intrusiveness model can be done by utilizing the IIRS. This method helps the counselor gather baseline data at the onset of therapy, as well as monitor progress and present problems and symptoms.

Second, breaking general goals into specific goals simplifies the process into step-by-step plans for achieving general goals. Third, prioritizing goals helps the client and practitioner to decide which goals should be addressed first to provide the most beneficial outcome from therapy. Fourth, charting emotional changes helps monitor progress toward reaching goals. One can track changes based on emotional intensity and frequency, as well as specific mood-related symptoms. Finally, if the client is not making progress toward the goals, the counselor should consider breaking goals into even smaller steps, thus addressing the impediment to progress and considering changes in the treatment plan (Padesky & Greenberger, 1995).

One of the many reasons that agreement and clarity in goal setting is important is that regardless of individual differences, therapeutic outcomes are more apt to be positive when the counselor and client move toward the same goals (Ju, 1982). It is important that, when a client with specific disabilities makes progress toward and ultimately accomplishes each goal, reinforcement is applied by the practitioner. Reinforcement should be put into practice with intentionality and only when it promotes the attainment of skills and behaviors that the client needs to meet objectives. This skill needs to be used systematically rather than randomly (Thomas & Parker, 1984).

Other techniques that can be employed during the therapeutic process are that of Socratic questioning and activity scheduling. The first occurs by having the practitioner facilitate the telling and retelling of the story until opportunities for new meaning and story content develop (Corey, 2005). The use of Socratic questioning with students with disabilities enables these clients to realize they possess an understanding of their problems and preconceived notions, thoughts, or beliefs, and can alter them by elaborating and discussing matters further. In sum, the use of one simple technique could have a profound impact on illness intrusiveness factors such as personal control, social and psychological factors, and life outcomes.

Activity scheduling is not only another important aspect of CBT, but also an effective tool for decreasing illness intrusiveness. By engaging the client in planned activities, the client is encouraged to take an active role in life, as well as rediscover activities that may have previously been enjoyed. By discerning likes and dislikes, the client is able to increase personal insight and lower levels of depression. Activity scheduling also enables clients to see that they are capable of not just choosing the level and type of daily activities, but also seeing the big picture in choosing the direction of life outcomes. By realizing that they are able to control these tasks, the clients will also begin to reframe their locus of control from external to internal.

Finally, cognitive behavioral counselors aim to teach clients how to be their own therapist (Corey, 2005). As with any case, the hope is that the client can walk away from counseling and make use of skills acquired throughout the therapy process, applying them in daily living without therapeutic assistance. Whether treatment is permanently terminated or titrated down, the outcome will directly impact illness intrusiveness through treatment factors, feelings of personal control, life outcomes, and psychological and social factors.

While research within this specific population is lacking, the application of CBT among persons with intellectual disabilities has shown varied results. For example, Gustafsson et al. (2009) found weak correlations between behavioral therapy, CBT, and other forms of integrated support, while others (Oathamshaw & Haddock, 2006) showed that persons with intellectual disabilities and psychosis could link events and emotions, and differentiate feelings from behaviors—all skills necessary to engage in CBT. While effectiveness among those with intellectual disabilities may or may not be applicable to other types of disabilities, it is worthy to note that evidence exists. It would be beneficial to add to this evidence by supporting the use of CBT in combination with the illness intrusiveness model among students with disabilities transitioning into postsecondary education. Furthermore, by implementing this treatment modality among all college students with disabilities, researchers and counselors would be able to establish whether this model is effective with specific disabilities, cases in which it may not be as useful, and ways treatment can be modified or enhanced. Utilizing the authors’ presented model, future research could aim to investigate treatment of different types of college students with disabilities (e.g., learning disabilities, psychiatric disabilities, attention deficit hyperactivity disorder [ADHD]) and examine the effectiveness, similarities, differences, or any future directions. Treatment may be implemented in both the individual and group setting, and individual changes should be monitored by means of the IIRS.

Summary

The use of CBT among college students with disabilities transitioning into the college atmosphere could have a vast impact on illness intrusiveness. While, to the current authors’ knowledge, no recent studies have looked at implementing this model and mode of treatment, it would be an area worth investigating. The convergence of an empirically supported model such as the illness intrusiveness model, as well as a theory having a preponderance of empirical evidence such as CBT, would be a solid foundation to begin implementation of therapeutic intervention.

The college student population will have to face many potentially problematic situations when transitioning into the world of continued education. Some struggles that may be encountered when assisting college students in transition who also have disabilities may relate to homework completion, organizational stills, appropriate accommodations (e.g., extended test taking time, use of a note-taker, use of assistive computer technology), transportation and living accommodations, and reliable social support systems. By addressing the above areas of concern, an efficacious treatment could be set into practice in order to adhere to professional and personal standards.

Kirsh et al. (2009) found that “disabled adults are twice as likely to be in a household with lower

incomes, and disabled people of working age are more than twice as likely as nondisabled people to have no employment-related qualifications” (p. 392). This is an essential point when discussing the importance of secondary schooling and continued education for persons with disabilities. If the statistics show that disabled persons are twice as likely as those without disabilities to have no employment-related qualifications, then accommodating them in the transition to the college environment seems appropriate. It makes sense to aid others in engaging and succeeding at their endeavors rather than waiting for them to fail or not assisting in the process at all. Counseling intervention and prevention could benefit those who may be struggling to persevere on their own, and implementation of the illness intrusiveness model in combination with CBT may provide to incoming college students with disabilities the appropriate coping skills to transition adaptively to the next phase of their life.

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Katie L. Haemmelmann, NCC, is a predoctoral intern at All Children’s Hospital and the Rothman Center for Pediatric Neuropsychiatry in St. Petersburg, FL. Mary-Catherine McClain is a predoctoral intern at Johns Hopkins University Counseling Center in Baltimore, MD. Correspondence can be addressed to Katie L. Haemmelmann, 3210 Stone Building, 1114 West Call Street, Tallahassee, FL 32306, klh08d@my.fsu.edu.