Using Mindfulness-Based Cognitive Therapy in Individual Counseling to Reduce Stress and Increase Mindfulness: An Exploratory Study With Nursing Students

Feb 9, 2015 | Article, Volume 5 - Issue 1

Mark J. Schwarze, Edwin R. Gerler, Jr.

The purpose of this exploratory study was to investigate the effectiveness of a modified mindfulness-based cognitive therapy intervention using individual counseling sessions to reduce stress and increase levels of mindfulness among nursing students. An AB single-subject experimental design replicated three times was implemented. Results indicated reduced stress in two out of three participants and increased mindfulness levels in all participants. Implications for college counselors and counselors working with clients in high-stress occupations are provided. Additionally, the results show promise for the use of mindfulness-based cognitive therapy in individual counseling.

Keywords: mindfulness, mindfulness-based cognitive therapy, stress, college counselors, nursing, single-subject experimental design 

Mindfulness-based cognitive therapy (MBCT) has been described as part of a third generation of cognitive therapies (Harrington & Pickles, 2009). Along with dialectical behavioral therapy and others like it, MBCT has integrated the construct of mindfulness with standard cognitive-behavioral paradigms. MBCT found its origins in the work of Kabat-Zinn’s (1990) mindfulness-based stress reduction program. This 8-week group-based program consisted of Buddhist mindfulness mediation practices to help chronic pain sufferers reduce their stress associated with illness. MBCT has incorporated elements of mindfulness-based stress reduction and cognitive-behavioral therapy to help individuals become more aware of thoughts and feelings and put them into context as mental events rather than self-defining constructs (Teasdale et al., 2000).

Seeing a need for an intervention to help patients who had repeatedly relapsed into depression, Segal, Williams, and Teasdale (2002) formalized MBCT as a standardized program of therapy. Designed as an 8-week program with specific guidelines for each session, MBCT was originally conceived as a group modality. Clients are placed in classes to learn the mindfulness and cognitive-behavioral (Beck, Rush, Shaw, & Emery, 1979) skills needed to regulate emotions and thoughts. MBCT involves training the mind to avoid judgmental reactions to events, thoughts, feelings and body sensations and to practice nonjudgmental awareness and acceptance (Ma & Teasdale, 2004). The key component of MBCT is mindfulness.

Mindfulness, once an abstract concept in the counseling field, is reaching mainstream awareness and gaining more attention in the literature (Brown, Marquis, & Guiffrida, 2013). Derived from Zen Buddhism, mindfulness has been described as a commitment to bringing awareness back to the present moment (Harrington & Pickles, 2009). Brown and Ryan (2003) defined mindfulness as “the state of being attentive to and aware of what is taking place in the present” (p. 822). Despite a growing research base, mindfulness as a testable and operationally defined variable is still being shaped.

Bishop et al. (2004) proposed an operational definition of mindfulness as a two-component skill-building approach for responding to emotional and cognitive distress. The first component involves the self-regulation of attention. Measurable skills must be obtained to reach a successful level of self-regulation of attention, including sustained attention; switching, or bringing the attention back to a focal point; and inhibition of elaborative processing, which involves the ability to maintain a state of flexible and nonjudgmental focus and awareness over a period of time. The second component includes developing an orientation to experience. In this, all thoughts, feelings and sensations are acknowledged.

Mindfulness training works well in counseling in that it is a simple idea: staying focused on momentary experience (Grabovac, Lau, & Willett, 2011). The core strategy to teach clients is mindfulness meditation. Meditation has many forms but is ultimately the practiced skill of quieting the mind (Wright, 2007). Counselors trained in meditation can teach clients to sit quietly and observe thoughts and feelings without reaction or judgment (Brown et al., 2013). A version of this meditation is the 3-minute breathing space (Segal et al., 2002). This meditation approach is a core skill learned in MBCT. It utilizes the breathing techniques of meditation while attempting to bring awareness to present experience, focusing on breath as a mediator and expanding to other bodily sensations.

     Because mindfulness is rooted in Buddhist philosophy and belief, its inclusion in Western counseling paradigms has been slow. Most interventions and models consisting of mindfulness-based ideas have been stripped of the Eastern religious and philosophical foundations and presented as skill-based acquisitions (Baer, 2003). This change has increased acceptance of mindfulness-based approaches in mainstream treatment and educational venues. Specifically, using mindfulness to mitigate stress has been a benefit of this practice. One particular population that has historically reported high levels of stress is nursing students (Beddoe & Murphy, 2004).

Nursing Students and Stress

The Spring 2013 American College Health Association’s National College Health Assessment (American College Health Association, 2013) listed stress as the number-one impediment to academic success for college students. Specifically, college students training to be nurses at the university level are subjected to high levels of stress (Gibbons, Dempster, & Moutray, 2011). Pulido-Martos, Augusto-Landa, and Lopez-Zafra’s (2012) review of the literature on the nursing student experience found several factors leading to stress, including balancing home and academic demands, experiencing time management pressures and financial problems, lacking meaningful connections with the nursing faculty, and feeling unprepared and incompetent in clinical practice.

In addition, stress, combined with other issues, has led to significant attrition rates in nursing programs (Harris, Rosenberg, & O’Rourke, 2014). Stickney (2008) found that the number of new students in nursing programs is too low to ensure an adequate number of nurses to meet the future needs of health care agencies. Students in nursing programs experience significant amounts of stress from trying to balance their lives at home with academic responsibilities. It is imperative that counselors, especially those in college settings, are aware of effective and innovative interventions to help nursing students, as well as other students, reduce stress and be successful. MBCT has shown promise in helping people reduce negative emotions such as stress (Collard, Avny, & Boniwell, 2008; Teasdale et al., 2000).

This study utilized a modified version of MBCT in individual counseling sessions to teach and process MBCT core skills of mindfulness meditation and cognitive decentering. While MBCT has mostly been utilized in group formats, there is some argument that group counseling is not always the best approach. Kuyken et al. (2008) found that 5% of an eligible sample for their MBCT study declined participation because they did not like the group aspect of the intervention. Lau and Yu (2009) suggested that offering mindfulness-based treatments in an individual format might increase participation for those who are reluctant to be involved in group settings.

The purpose of this exploratory single-subject experimental study was to evaluate the effectiveness of using MBCT to help reduce stress among university nursing students. Nursing students were used because of their documented high levels of stress. The questions explored included whether using MBCT in individual sessions increases self-reported levels of mindfulness and decreases self-reported levels of stress.

Method

Research Design

Single-subject design has a long history in psychological and counseling research (Heppner, Wampold, & Kivlighan, 2008). Barlow and Hersen’s (1984) exposition on the chronology of single-subject design reveals that psychology’s early research development was steeped in the use of this type of experiment. Lundervold and Belwood (2000) called single-subject experimental design “the best kept secret in counseling” (p. 92). This design can provide counselors with scientific methods of research that produce practical and useful clinical information that can be applied to practice settings.

There are several advantages of using a single-subject experimental design. It allows the researcher to narrow causes of behavior change and determine which treatment approaches are most effective. Group designs often can obscure change in individuals, thereby not allowing flexibility in modifying treatment protocols to isolate examples of cause and effect (Barlow & Hersen, 1984). Morgan and Morgan (2003) posited single-subject design as the best option when trying to explain individual differences. Another advantage of single-subject experimental design is that because the researcher collects data using a baseline and intervention phase, the subject acts as his or her own control group, thereby increasing internal validity (Sharpley, 2007). Additionally, single-subject design can allow for scrutiny of new and innovative approaches (Chapman, Baker, Nassar-McMillan, & Gerler, 2011). Specifically, this study utilized a basic single-subject experimental AB design that allows for a maximum clinical utility.

Participants

     Participants in this study were all senior-level students enrolled in a Bachelor of Science in Nursing (BSN) program at a small rural Southeastern university. Four of the participants were female and one was male. Participant ages ranged from 21–30 years old (mean age 25.6 years). Three of the participants were Caucasian, one was Hispanic American and one was Native American.

The sample was recruited from students enrolled in the upper division pre-licensure BSN program and fully engaged in all activities and requirements of the program, including clinical work at local hospitals in order to develop basic and advanced nursing skills. Recruitment involved presenting the study and requirements for participation to a class for senior nursing students and sending an e-mail to all junior and senior students, yielding five volunteers. Two of the participants dropped out of the study after intervention sessions two and three, respectively. (More discussion and analysis about participant attrition is presented in the results section.)

Measures

The Perceived Stress Scale (PSS) was developed by Cohen, Kamarck, and Mermelstein (1983) to measure the degree to which one evaluates situations and events in his or her life as stressful. Specifically, the 10-item version of the PSS (PSS-10; Cohen & Williamson, 1988) measures the degree to which one perceives life as uncontrollable, unpredictable and overloading. The PSS-10 typically requires participants to answer questions based on their experiences in the past 30 days. A modification for this study was asking participants to answer the questions based on their experiences and thoughts in the past 7 days, as the study was focused on weekly variability. The PSS-10 has a Likert-type rating scale and is widely used as a measure of perceived stress. It is shown to have internal reliability (coefficient alpha of .78) with established construct validity, as the PSS-10 scores have shown moderate relation to other measures of appraised stress. Scores can range from 0–40, with higher scores indicating greater stress. Roberti, Harrington, and Storch (2006) found the PSS-10 reliable and valid with a non-clinical sample of college students. Mean scores for males were 17.4 (SD = 6.1); mean female scores were 18.4 (SD = 6.5).

Also used in the study was the Mindful Attention Awareness Scale (MAAS), a 15-item scale designed to measure characteristics of openness or receptiveness to what is taking place in the present (Brown & Ryan, 2003). The MAAS aims to assess the level at which one is able to observe what is happening without judgment. The MAAS assesses the absence or presence of mindful mental states over time. For this study, participants were asked to form their answers based on experiences and thoughts over the past 7 days. Normative information is available for college populations (14 independent samples: N = 2,277; M = 3.83, SD = .70). Cronbach’s alphas range from .80–.90. The MAAS also has shown high test-retest reliability, discriminant and convergent validity, and criterion validity (Brown & Ryan, 2003). MacKillop and Anderson (2007) confirmed validity and reliability of the MAAS with internal reliability scores of .89.

Procedure

     Participants volunteering for the study were scheduled individually for an appointment to meet with the researcher to complete a study orientation and start baseline measurements. This 30-minute meeting consisted of an introduction to the study and the researcher, obtaining a brief background of the participant, a definition of mindfulness, completion of the informed consent paperwork, and completion of a short participant demographic form. Additionally, the first baseline measurements with the PSS-10 and MAAS were collected at the end of this meeting, and the final three baseline measurements were scheduled. Each baseline meeting consisted of an informal discussion about academic and personal stress levels and completion of the dependent measures. In total, four baseline measurements were collected over 5 weeks.

The intervention phase (B) consisted of six 1-hour sessions conducted over 5.5 weeks starting at the conclusion of the baseline phase (A). Session one began on the first week of classes in a spring semester, and sessions two through five occurred during each subsequent week. The final session, a wrap-up and review, was scheduled for the beginning of week six of the intervention. Each session consisted of 50 minutes focusing on MBCT skills, concepts and homework assignments, and 10 minutes at the end of the session to administer the dependent measures. At the final session, the researcher explained procedures and options for counseling if the participant desired to continue exploring MBCT or other issues that may have come up during the study period. Additionally, all participants received mindfulness resources such as book and Web site lists in order to continue learning and practicing mindfulness exercises.

MBCT Intervention

MBCT is traditionally an 8-week intervention conducted in group or class settings (Teasdale et al., 2000). Because this study utilized individual counseling, the intervention was reduced to six sessions, and session length was reduced to 1 hour. The individual counseling modality allowed for more focused attention to participants, and exercises could be consolidated. Also, MBCT was originally used to treat clients with chronic relapsing depressive disorders, while stress was the target symptom in this study. Due to this shift in focus, some of the exercises and homework assignments relevant to those who might have depression were not included in the intervention. Another modification included the use of prerecorded guided meditations for body scans and breathing instead of researcher-led meditations. During sections of the intervention when a meditation was introduced and practiced, the researcher started a prerecorded meditation and left the room while the participant experienced the meditation. The prerecorded breathing and body scan meditations used for this study were from the Maddux and Maddux podcast (2006).

The modified intervention still utilized the core MBCT exercises and philosophy. The next section includes a description of the major techniques used and what modifications were made to accommodate the study goals. Also included is an outline of the six session themes. Theme 1: Using Mindfulness to Break Out of Automatic Pilot focuses on an orientation to mindfulness and techniques to develop a heightened awareness of the present moment. Theme 2: Focus on the Body Enhances Clarity of the Mind, and Theme 3: Mindfulness of the Breath introduce the exercises of the body scan and breathing mediation. Theme 4: Acceptance promotes nonjudgmental acceptance of events, cognitions and emotions. Theme 5: Thoughts Are Not Facts is an educational session about cognitive-behavioral philosophies and their impact on moderating emotions. Theme 6: Putting It All Together provides a summary of the ideas and techniques of MBCT, with suggestions on how to integrate the concepts daily. The modified structure and content used is unique to this study; however, the specific components, homework and exercises are taken from Segal et al. (2002). Table 1 describes the schedule and order of session content, including session themes and agendas.

MBCT Techniques and Exercises Used in the Study

     Raisin exercise. Used as an introduction to mindfulness, this exercise asks participants to take a raisin offered by the researcher and examine all aspects of its shape, texture and external characteristics. Open-ended questions are asked to help participants explore their experience.

Body scan meditation. The exercise brings a detailed awareness and focus to specific areas of the body. A modification in this study included using a shorter meditation (8 minutes; Maddux & Maddux, 2006).

Be mindful during a routine activity. Participants are asked to choose a routine activity (e.g., brushing teeth, vacuuming, washing dishes) and to complete it mindfully per the study’s training.

     Homework record forms. Used in all sessions, these forms allow participants to document the frequency of practice of mindfulness activities.

     Thoughts and feelings exercise (professor sends an e-mail). In this exercise, the researcher presents a scenario to elicit participant reaction.

Pleasant and unpleasant events calendars. Participants receive forms (Segal et al., 2002) that help them identify one pleasant event per day in week two and one unpleasant event per day in week three.

Five-minute hearing exercise. Participants are asked to sit for 5 minutes with eyes closed and center all of their focus on hearing. When intrusive thoughts enter, participants are instructed to acknowledge them, but then return their focus to only hearing.

     Three-minute breathing space. A core skill in MBCT, this exercise acts as a mindfulness timeout.

Twenty-minute sitting meditation. This meditation is a combination of all the skills participants have learned, including the body scan, breathing meditations and the hearing exercise.

Moods, thoughts and alternative viewpoints discussion. This exercise involves a short overview of how thoughts can influence mood, and techniques and suggestions for viewing intrusive thoughts in a different way. Handouts titled Ways You Can See Your Thoughts Differently and When You Become Aware of Negative Thoughts are provided (see Segal et al., 2002).

Breathing meditation. This exercise brings a detailed awareness and focus to the breath. A modification in this study included using a shorter (9 minutes) recorded breathing meditation (Maddux & Maddux, 2006).

Mindfulness resources handout. Researchers generate a list of books, Web sites and podcasts that describe mindfulness and the techniques associated with the study. The participants receive this at the last session with encouragement to continue to seeking information on mindfulness practice if they have found it helpful.

Table 1

Schedule and Order of Session Content

Results

All five participants completed the baseline phase (A) of four weekly meetings to complete the dependent measures.  A₁–A₄ represent weeks one through four of the baseline phase_. Out of five participants, three participants completed the full intervention phase (B) of six weekly 1-hour sessions. B₁–B₆ represent weeks one through six of the intervention phase. The phases ran consecutively. One participant completed only two of the intervention sessions before withdrawing from the study. This participant cited a variety of issues including unexpected sickness and time constraints as deciding factors for withdrawal. Another participant completed three intervention sessions before withdrawing, citing time constraints and academic demands as reasons for withdrawal. The researchers have included the results for only the three participants who completed the full intervention, due to the importance in single-subject designs of multiple measurements of the dependent variable occurring over the complete span of the study in order to determine changes in self-reports of mindfulness and perceived stress. It is the comparison of the two full phases that allows interpretation of whether the intervention was the cause of the change.

Participant 1

Participant 1 reported no previous experience with mindfulness activities. The baseline mean score on the PSS-10 for Participant 1 was 21.75. This baseline mean score is higher than that of the normative sample and indicates some experience of perceived stress. The baseline mean score on the MAAS was 3.07. This baseline mean score is lower than that of the normative sample and indicates less self-report of mindfulness as measured by the MAAS. The individual scores over the baseline period for the PSS-10 fluctuated, which may be related to the time of administration. The A₁ and A₄ scores were both 22, and both measurements were taken at high-stress academic times. However, Participant 1 earned the highest score in the baseline phase (25) at A_3, on Christmas Eve. These scores support the literature that found several factors leading to nursing student stress, including home and academic demands (Magnussen & Amundson, 2003). Alternately, the individual scores over the baseline period for the MAAS were mostly stable with a significant drop in A_4, which was collected on the last Friday before the spring semester started. With the focus that mindfulness places on staying in the present moment, as measured by the MAAS, the anticipation of the new semester may have taken precedence. Essentially, baseline scores on the PSS-10 were variable, as were the academic and home stressors, and MAAS scores were relatively stable, but below normative scores for college populations.

The intervention mean score on the PSS-10 was 23. This score was 1.25 points higher than the baseline mean of overall self-reported stress as measured by the PSS-10. The individual scores of the intervention phase showed decreasing PSS-10 scores from B₁–B₃ while showing increasing MAAS scores at the same time for Participant 1 (see Figure 1). B₄ showed a 1-point increase from B₃ in PSS-10 scores, which coincided with Participant 1 experiencing a medical emergency. Despite this crisis, stress scores increased only minimally while mindfulness scores increased by .47 from B₃–B₄.

MAAS scores continued to increase throughout the intervention phase, with the highest score of 4.93 reported at the final session. This finding indicated that increased exposure to and practice of mindfulness activities correlated with higher self-report of mindfulness scores. This result was confirmed by an increase of 0.88 in the mean scores on the MAAS from baseline to intervention and a gain of 2.73 from B₁–B₆ (see Figure 1). Table 2 provides the dependent measure scores for Participant 1.

Participant 2

Participant 2 reported no previous experience with mindfulness activities. The baseline mean score on the PSS-10 for Participant 2 was 22.25. This baseline mean score is higher than that of the normative sample and indicates some experience of perceived stress as measured by the PSS-10. The baseline mean score on the

Table 2

Dependent Measure Scores for Participant 1

Note. Sessions A₁–A₄ were baseline sessions; sessions B₁–B₆ were intervention sessions.

MAAS was 2.9. This baseline mean score is lower than that of the normative sample and indicates less self-report of mindfulness as measured by the MAAS. The individual scores over the baseline period for the PSS-10

showed an increase in stress scores, with the highest baseline score (25) coming at A_4. The individual scores over the baseline period for the MAAS were stable with the lowest score (2.33) reported at A₁. Baseline scores on the PSS-10 increased and MAAS scores were stable once past the initial baseline meeting, but still remained below the normative scores (see Figure 2).

The intervention mean score on the PSS-10 was 25.17. This score represents a 2.92-point gain from the baseline mean in overall self-reported stress as measured by the PSS-10. However, there was a drop of five points on the PSS-10 from B₁–B₂. MAAS scores continued to increase throughout the intervention phase with highest score of 3.73 coming at the final session. There was an increase of 0.54 in the mean scores on the MAAS from baseline to intervention and a gain of 0.46 from B₁–B₆. Table 3 lists the dependent measure scores for Participant 2.

Table 3

Dependent Measure Scores for Participant 2

Note. Sessions A₁–A₄ were baseline sessions; sessions B₁–B₆ were intervention sessions.

Participant 3

Participant 3 reported no previous experience with mindfulness activities. The baseline mean score on the PSS-10 for Participant 3 was 20.75. This baseline mean score is higher than that of the normative sample. The baseline mean score on the MAAS was 2.7. This baseline mean score is lower than that of the normative sample. The individual scores over the baseline period for the PSS-10 showed a baseline high of 27 at A_1. PSS-10 scores dropped eight points from A₁–A₂.

The individual scores over the baseline period for the MAAS were stable from A₂–A ₄ with the lowest score (1.93) coming at A_1. Participant 3 posted stable baseline scores on both the PSS-10 and the MAAS except for at the first baseline meeting. At this meeting, the stress score was high and the mindfulness score was low.

The intervention mean score on the PSS-10 was 22.17. This score is a 1.42-point gain from the baseline mean in overall self-reported stress as measured by the PSS-10. There was a significant drop of seven points on the PSS-10 from B₃–B_4, and drops in stress score continued throughout the rest of the intervention phase.

MAAS scores continued to increase throughout the intervention phase with highest score of 5.13 coming at the final session. This is an increase of 1.1 in the mean scores on the MAAS from baseline to intervention and a gain of 3.46 from B₁–B₆ (see Figure 3). Table 4 lists the dependent measure scores for Participant 3.

Table 4

Dependent Measure Scores for Participant 3

Note. Sessions A₁–A₄ were baseline sessions; sessions B₁–B₆ were intervention sessions.

Discussion

The results indicate that exposure to an MBCT intervention can positively impact self-reported stress scores as measured by the PSS-10 and increase self-reported mindfulness scores as measured by the MAAS. All participants in this exploratory study showed gains in mindfulness levels as measured by the MAAS. These results likely occurred due to the fact that most participants began the study with no knowledge of or experience with mindfulness. Once exposed to the practice of meditation and other mindfulness exercises, the participants’ use of mindfulness processes increased steadily.

PSS-10 scores fluctuated during the baseline phase, and that variability could be explained by academic events, evaluative and anticipatory, occurring at the time of administration of the dependent measures. Specifically, the A₁ and A₄ scores for Participant 1 were both 22. Both of these measurements were taken at high-stress academic times. However, Participant 1’s highest score in the baseline phase (25) came at A_3, on Christmas Eve. These scores support the literature that found several factors leading to nursing student stress, including home and academic demands (Magnussen & Amundson, 2003; Pulido-Martos et al., 2012). Consequently, all three participants posted their lowest mindfulness scores on days that coincided with a high-stress academic event such as final exam week, or the day before the first week of classes. However, once the MBCT intervention phase began, two of the participants (1 and 3) showed steady drops in PSS-10 scores, and the third (2) showed conservative reductions, suggesting that the intervention was a likely factor in decreasing perceived stress among the three participants. However, Participant 3’s PSS-10 scores revealed a 1.42-point gain from the baseline to intervention mean. The overall gain in the intervention mean score can be attributed to an unusually high score of 28 on B₃. Participant 3 did report increased personal and academic distress at this time in the study. This result also could indicate that the benefits of mindfulness practice can be preempted by reactive stress to specific events. More long-term practice of mindful activities might have mitigated the stress of these events.

Participant 2 posted an overall 2.92-point gain from the PSS-10 baseline mean score to the intervention mean score. This increase may be attributed to an unusually high score of 28 on B₁, perhaps because the first session of the intervention fell on the first week of classes for the spring semester. Additionally, Participant 2 had only 50 minutes of exposure to mindfulness activities at this time. However, there was a drop of five points on the PSS-10 from B₁–B₂. This decrease might be attributed to some type of novelty effect from being introduced to a new treatment (MBCT). This argument is strengthened by the fact that Participant 2 posted stable stress scores throughout the rest of the intervention. It should be noted that Participant 2 informed the researchers after B₄ of the need to withdraw from the study due to time constraints and academic demands, but eventually decided to finish the study. This participant acknowledged feeling some personal distress throughout the next two sessions but did not report the need for any additional intervention. For Participant 2, it appears that MBCT was successful overall in increasing self-reported mindfulness levels as measured by the MAAS. Based on the small decreases in PSS-10 scores over time, and the continued self-report of personal distress through the final session, the MBCT intervention was only minimally successful in stress reduction for Participant 2.

Homework assignments and additional meditation practice were highly encouraged in this study, but not required. All participants chose to complete some homework and practice meditations outside the study sessions; however, the reported time spent on meditation practice varied significantly. Ancillary findings from Collard et al. (2008) found a correlation between longer practice times of mindfulness and higher levels of mindfulness. An analysis of the data surrounding participant practice time and levels of obtainment of mindfulness would have been an interesting component to include in this study.

Limitations

One disadvantage of this study is the inherent limitation of single-subject design—specifically, external validity. Because this study included separate experiments with data on only three cases, it is difficult to make generalizations. However, external validity can be enhanced by replicating the design multiple times, thus strengthening possibilities for generalizations (Heppner et al., 2008; Hinkle, 1992). Additionally, Hinkle (1992) discussed issues related to the AB design, specifically stating that “cause and effect cannot be explicitly determined” (p. 392).

The sample was motivated enough to volunteer for the study, which may mean that participants were more stressed than other nursing students and more motivated to seek solutions for stress. Alternatively, the willingness to volunteer for the study may have meant that these participants were less stressed and had more free time to participate in a weekly intervention. Another limitation was the modifications made to the MBCT intervention to accommodate the individual counseling modality. However, because of the exploratory nature of the study, modifications in future studies are warranted.

The use of only one dependent measure for each dependent variable also presents limitations. The PSS-10 and the MAAS measure self-reported stress and mindfulness. The use of other instruments or data to measure the two dependent variables might have strengthened the study. Specifically, a mixed-methods design could have focused on the provided quantitative measures as well as qualitatively analyzing the homework forms and the participant’s verbal session content. Potentially, because of the timing of the study, and because stress is often linked with college student academic failure (American College Health Association, 2013), final exam grades and midterm grades could have been compared to assess for academic changes based on the introduction of the intervention.

Implications for Counseling

This study strengthens the growing research base on the use of MBCT. Specifically, it adds to the literature supporting the efficacy of MBCT in reducing stress. A unique contribution is the use of MBCT in a single-subject experimental design. Typically, MBCT is used in a class format; this study supports the potential efficacy of MBCT in individual sessions.

Based on the above implications, this study also has implications for college counselors and counselors who work with those in stressful professions. Due to high attrition, academic distress and high-stakes testing, colleges are struggling to help their students succeed. College counselors provide services that address the academic and personal well-being of students. This study indicates that the use of MBCT in individual counseling to mitigate stress can yield promising results.

College counselors and faculty members can work together to provide mindfulness-based workshops or other activities that promote a meditative approach. Developing effective partnerships should begin with an assessment of available mindfulness resources. Program administrators want their students to be successful and may be willing to integrate resources from outside the program. Many colleges and universities might have trained counselors on staff who can provide these services. If not, negotiations with certified off-campus meditation or yoga centers could provide reduced rates for students. More importantly, counselors can train faculty members in mindfulness exercises that they can integrate into the fabric of their programs. Embedding mindfulness into academic programs could be more effective and efficient if students perceive it as part of their education instead of an add-on.

College counselors will do well to learn the language and culture of the academic programs on their campus. Crafting mindfulness interventions to correspond directly with the stressors of a certain program might help develop rapport with students. This process could be collaborative, involving college counselors, educators and students. Also, sharing data gathered from program evaluations or studies with administrators can strengthen relationships by assisting with long-term programmatic goals.

Future Areas of Research

Future areas of research should include the use of MBCT and other mindfulness-based interventions in order to replicate these results. More research is needed on delivering MBCT in an individual format. Another component of this study that needs more exploration is whether a longer amount of time spent practicing mindfulness activities provides greater relief from self-reported stress symptoms. The next logical step is to complete a study using a larger sample. Experimental studies comparing the effects of MBCT with more traditional counseling approaches aimed at reducing stress and improving performance could prove useful. How, for example, might MBCT compare to rational-emotive or rational-behavior approaches to reducing stress? Additionally, given the evolving nature of technology-based counseling interventions, future research on MBCT also might explore the value and usefulness of online MBCT interventions. Examining and comparing the effectiveness of synchronous versus asynchronous MBCT interventions would be especially valuable.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.

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Mark J. Schwarze, NCC, is an Assistant Professor at Appalachian State University. Edwin R. Gerler, Jr. is a Professor at North Carolina State University. Correspondence can be addressed to Mark J. Schwarze, Reich College of Education, Department of Human Development and Psychological Counseling, 151 College Street, Appalachian State University, Box 32075, Boone, NC 28608-2075, schwarzem@appstate.edu.

A Counseling Formula: Introducing Beginning Counseling Students to Basic Skills

Feb 9, 2015 | Article, Volume 5 - Issue 1

Susan A. Adams, Alice Vasquez, Mindy Prengler

Teaching basic skills to beginning counseling students can be an overwhelming experience. In each therapy session, students bring their own human qualities and life experiences that have shaped them as individuals. Trainees must understand that their needs, motivations, values and personality traits can either enhance or interfere with their counselor effectiveness. Cognitive mapping can help expand students’ awareness while building the foundation of their counseling skills because it involves practical integration of learning attributes and prior knowledge into a new situation. Through the use of simple graphic visual learning tools, students can successfully incorporate basic skills into their development as counselors in an attempt to enable a positive initial learning experience that does not overwhelm them with the nuances and complexities of advanced counselor development.

Keywords: counseling students, basic skills, counseling formula, cognitive mapping, graphic visual learning tools

     Why does change occur in therapy? Theorists have attempted to answer this question over the decades. Certainly the starting place is to focus on the importance of the therapeutic relationship, which is “central and foundational to therapeutic growth” (Slattery & Park, 2011, p. 235). Specifically, the outcome of counseling involves a connection between the counselor and client that begins with warmth, empathy, respect and genuineness (Chang, Scott, & Decker, 2009; Flaskas, 2004; McClam & Woodside, 2010; Smith, Thomas, & Jackson, 2004).

     Rogers (1951, 1957, 1958) discussed his ideas about unconditional positive regard, congruence and empathy as basic key factors in the development of a therapeutic relationship. Moursund and Kenny (2002) summarized Lazarus’ perspective and proposed that establishing the therapeutic relationship is the most important skill for clinicians, and involves a connection between the counselor and the client. Each influences the other by bringing individual strengths, knowledge of the situation, life experiences, as well as their own personal values and beliefs. “The therapeutic relationship is viewed as both a precondition of change and a process of change” (Prochaska & Norcross, 2003, p. 492). The purpose of this article is to explore one method of breaking down basic counseling skills into a manageable counseling formula in order to enable a positive initial learning experience for students without overwhelming them with the nuances and complexities of advanced counselor development.

Challenges of Mastering Basic Skills

Initially, when introduced to counseling basic skills from a written textbook, students can find acquiring this knowledge to be challenging. Without prior experience, the challenge may intensify and become daunting when successful academic progress becomes an expectation defined by mastery of clearly defined basic skills. Counseling students struggle to appropriately apply these skills, while linked with timing and delivery.

Counseling is a unique experience that is different from daily communications in social interactions. As counselors-in-training learn the art of counseling, they become aware of the necessity of using their skills to empower their clients to set appropriate goals. Often empowerment, a concept that focuses on clients’ ability to choose their own solutions in life situations and issues, is a lofty ideal that is difficult to define. Even the definition of empowerment is ever-evolving (Asimakopoulou, Gilbert, Newton, & Scrambler, 2012). Empowerment’s overarching theme further contributes to the complexities of the learning process for beginning students (Hill, 2005).

While no one would argue the importance of empowerment or the significance of the therapeutic relationship, it also is critical that beginning students master many interpersonal skills while learning to observe, effectively attend to, and play an interpersonal role in shaping and guiding the counseling session (Ackerman & Hilsenroth, 2001; Chang et al., 2009; Jacobs, 1994; Jacobs, Masson, Harvill, & Schimmel, 2012; Meier & Davis, 2011). In fact, the second belief of Jacob’s impact therapy is that “people don’t mind being led if they are led well” (1994, p. 8). Therefore, it becomes imperative that educators incorporate logical process teaching methods in order to simplify this initial learning process, and cognitive mapping pedagogy provides that logical process.

Cognitive Mapping Pedagogy

A concept map is “a schematic device for representing a set of concepts and meanings embedded in a framework of propositions” (Novak & Gowin, 1984, p. 15). According to Akinsanya & Williams (2004), cognitive mapping provides an interactive teaching environment incorporating communication, group dynamics and motivation. Concept maps promote awareness of the roles of relationships within the categories and are ideal for the measurement of students’ learning (Akinsanya & Williams, 2004). Nurses have been successful in the utilization of cognitive mapping in order to build upon new concepts and incorporate these new concepts into their working framework. The cognitive mapping strategy ensures that both the curriculum and learning processes align with the nurses’ practical application of patient care (Akinsanya & Williams, 2004).

Counselor educators, in an initial basic skills course, focus on improving how students understand their basic counseling skills and navigate their individual learning styles. The counselor educator’s goal is for students to become successful counselors. Creating a classroom of trust filled with simplistic, graphic learning tools can generate a safe learning environment and reduce anxiety. “The reduction of anxiety removes unnecessary barriers to learning and to performing complex, multidimensional, and multisensory tasks, of which counseling is a prime example” (McAuliffe & Eriksen, 2002, p. 50).

Furthermore, by using graphic learning tools, the counselor educator links what is in his or her mind with what is in the student counselor’s mind in order to enable the student counselor to effectively utilize past experiences with new knowledge. In other words, cognitive mapping helps graphically relate a foreign concept to prior learning experience by using experiential links between old knowledge and new learning. These experiential links create a deeper level of learning (Akinsanya & Williams, 2004). By using cognitive mapping in this research, the counselor educator forms a visual representation of the links of communication between student counselor and client. The cognitive mapping visual representation can track student counselor awareness with the communication of the client.

Cognitive mapping helps the student understand the structure of knowledge by providing a process for acquiring, storing and using information. This process helps students think more effectively by creating a pictorial view of their ideas and concepts and how these are interrelated (Kostovich, Poradzisz, Wood, & O’Brien, 2007). Svinicki and McKeachie (2011) explained that visual cues serve as points of reference. Using a diagram or other graphic representative, in addition to an oral presentation, serves as a point of reference for visual cues to enhance learning opportunities within cognitive mapping, which in turn gives the students a visual representation that supports learning. According to Veletsianos (2010), students have learning expectations before the learning process begins. Both learning preferences and personality style are incorporated into the students’ learning process. As Veletsianos discovered, when given a graphic such as a cognitive map, the material is organized in a way that influences students’ “expectations, impressions, and learning” (2010, p. 583). The combination of human interaction with a visual graphic as part of the classroom experience allows the student to expect that learning is about to occur.

Concept mapping helps the counselor educator track the progress of student learning by allowing the professor to track what the student does not understand. The role that the common language plays in concept mapping allows the counselor educator to correct the links that might confuse the student. Cognitive mapping is not only a visual tool, but also adds verbal and kinesthetic tools to role playing in initial counselor training courses.

According to Henriksen and Trusty (2005), development of specific counselor education pedagogy also must incorporate diversity. Cognitive mapping is a schematic tool that appeals to the diverse learner since it provides a progressive visual that counseling students can follow and understand (Hill, 2005). Cognitive mapping is diverse in itself, as it appeals to a variety of learning styles, culturally diverse students and adult learners. Students have consistently given feedback that this method of teaching has simplified both learning and understanding how the map fits together within the therapeutic process. The following examples provide a reflection of students’ perspective.

Student Feedback

Example 1. Typical students learn systematically as they acquire practice and understand how to apply the counseling formula to what is happening in their sessions. One of the current authors was taught the counseling formula during her first clinical graduate course and describes her experience this way:

For me, I could plug in where my parts were and back off on parts where the client needs to do his or her work. It made me feel more confident as I entered my second tape recording and verbatim assignment because I knew that my basic skills of reflection of content, feelings, and meaning would get me where I needed to go with my client. This is where he or she could begin to gain insight into their experience, and begin to have the option to make optimal changes in life.

Example 2. Struggling students are those trying to connect the dots until they apply the cognitive mapping formula to what is happening when working through their second tape. This student defines his experience and the insights he gained as follows:

When I was introduced to the counseling formula, I thought it was definitely something useful, but not something I fully grasped at the time. Before that point, everything I had learned had been more complex, and the formula seemed almost too simple. How could reflection of feeling and content lead to reflection of meaning? Also, how is the client able to know or receive the response the way the counselor wants him or her to? I was confused because the formula seemed so black and white—or at least that is how I made it out to be.

After our second counseling tape was recorded, our transcription was scored. To my surprise, I did not do well. I met with my professor who had taught me the formula at the beginning of the semester. Instead of her telling me exactly where in the formula I had gone wrong, we discussed what elements I was missing during the session and what I focused on too much. As we discussed my struggles, I kept the formula in mind. As we talked, I realized I had forgotten one of my key formula elements; I was stricken by the realization that I did not understand how to make meaning of this seemingly simplified equation. In no way is the equation simple as it is up to the counselor to do his or her part so the client can do theirs. This light bulb moment was a key part of my learning experience during my first basic clinical course.

Counselor Educators

A counselor educator developing a counselor training program that is culturally diverse can use cognitive mapping as a teaching tool to meet the needs of culturally diverse learners. Cognitive mapping provides counselor educators with a multicultural pedagogy which incorporates the race and ethnicity of their students during counselor training (Henriksen & Trusty, 2005). As a multicultural pedagogy, it further reduces cultural clashing by providing common, visual language (Dansereau & Dees, 2002). The cognitive map becomes the students’ tool for spoken language, as it parallels verbal thought and expression by breaking down complex thoughts into visual expression. Cognitive mapping, although an effective tool, is more likely to be effective with African Americans and Mexican Americans than Caucasians (Van Velsor & Cox, 2000). The cognitive map represents knowledge graphically; therefore, students whose initial language is not English can pictorially grasp the concepts with more ease.

Just as culturally diverse students can learn using cognitive mapping, adult learners also can benefit from using this schematic tool. According to Hill (2005), cognitive mapping or concept mapping (as she refers to it) is a learning tool that is well suited to the adult learner due to greater accumulation of experiences. Adult students find cognitive mapping useful in organizing their ideas, retaining information and relating content material to other knowledge. When processing content material using cognitive mapping, meaningful learning occurs; the adult student learner engages complex cognitive structures within the brain integrating it with existing knowledge.

Student Feedback

Example 3. A student who is a mature adult learner and whose second language is English shared that she learns better visually and that cognitive mapping helped her comprehend the content as she followed graphically what the counselor educator was explaining. She stated the following:

I am an older Hispanic student and English is my second language. Although I have excellent command of the English language, I still find myself translating from English to Spanish to better understand what the professor is saying. When the professor taught us the counseling formula in class, the methodology of how the counseling process works made sense to me. I was able to visualize in my head how the counseling process functions. From that point on, I was able to grasp the concept of what I need to do as a counselor to get clients to move toward change.

Theory & Basic Skills

The counseling process influences the outcome of counseling. This simple statement can easily lead to a developmental crisis as counseling students struggle with skill acquisition. According to Meier and Davis (2011), “To master process, beginning counselors must develop a repertoire of helping skills as well as a theory of counseling that directs their application” (p. 1). Most counseling programs separate acquisition of basic skills from theoretical knowledge. Gaining these skills can be like learning a foreign language—learned patterns of human interaction change as students assume their counselor identity and acquire new counseling skills.

Certain critical skills are absent from this formula because, due to prior knowledge and experience, students easily understand them. For example, when given the opportunity to talk about attending skills, most students can easily identify basic posture, facial expressions and space limitations with reasonable accuracy. Minimal encouragers and questioning are both necessary skills that have a useful purpose in the counseling session; nevertheless, students usually have mastered these in normal daily conversation. Therefore, both minimal encouragers and questioning must receive great attention in order to substantially reduce and manage their utilization and avoid hindering or distracting from the effectiveness of a counseling session.

A Cognitive Mapping Formula

The creation of a cognitive mapping formula for counseling was designed to graphically depict the counseling process utilized in the therapeutic process. The formula and the inclusion of certain basic skills illustrate the concept of client empowerment so that clients can take personal responsibility for their actions and make desired changes. The counseling formula works as follows: Cognition (C) plus feelings (F) equals meaning (M), which leads to awareness (A), which promotes insights (I), which facilitates change (see Figure 1).

Through reflections of cognition, feeling and meaning, counselors help clients explore their world and determine what will be effective and ineffective. These reflections encourage exploration on multiple levels. Deeper levels of exploration are achieved through reflection of feeling and meaning so that clients connect what is happening in their heads (cognitions) and what is happening emotionally (feelings), therefore ultimately understanding their experience (meaning). Through counselors’ proper application of the top line of the cognitive mapping equation, clients begin to understand that their situation is solvable if they are willing to take personal responsibility for the change, as reflected in the bottom line of the equation. In other words, change occurs as a result of clients’ personal commitment. The concept of universality and the inclusion of all basic skills are part of all theoretical applications.

The didactic application of the cognitive mapping, as seen in Figure 1, tracks how the counselor shapes the session in classroom role plays. The equation shows how the session crosslinks and builds. The counselor influences the session through the choices the counselor makes to reflect feeling, meaning or cognition. Each counseling session looks different, but all sessions need balance in order for sessions to flow.

Subsumed within this simplistic graphic are additional important counseling skills. Paraphrasing and summarization contain elements of cognition, feeling and meaning, and tend to center the client in the content of these elements. While using content elements is not negative, doing so sparingly prevents clients from intellectualizing their issues and avoiding taking responsibility for their desired change. Silence is located between the elements of cognition, feeling and meaning on the first line of the formula as a counseling skill, but is not represented in the graphic because of the invisible nature of this skill. The absence of spoken words can have a significant impact on the session if used appropriately, allowing clients the opportunity to think about, process and often discover insight related to their personal struggle.

A concept map can be applied to learning basic skills; it also can be applied to connect theory application and theoretical interventions with basic skills. An open umbrella is an excellent graphic that unites these disjointed pieces and crystallizes them into a working concept. The metal ribs of the umbrella are basic skills. The ribs provide the structure of the session and are the tools counselors use to work with their clients. The fabric of the umbrella is the theory imagery application. Theory and basic skills work together to determine how counselors do their job, just as the metal frame and umbrella fabric work together to do their job, which is to keep the user protected from the elements. Umbrella fabric comes in different colors and patterns, and so do counseling theories. Each counselor must find one that fits his or her style, personality, and perspective or viewpoint on how clients are best helped (Evans, Hearn, Uhlemann, & Ivey, 2011; MacCluskie, 2010).

The handle of the umbrella is important since it provides something to hold on to, and comes in various shapes and sizes. Some handles collapse so that the umbrella will fold up and can be carried easily in a briefcase or purse. Some handles are rigid, and can serve another purpose such as providing walking assistance. Counseling techniques, or therapeutic interventions, are the equivalent of the umbrella handle, since it is possible to utilize a variety of techniques with more than one theoretical orientation. Techniques are versatile and can be a significant part of the session, just as the handle is a significant part of the umbrella. However, students must understand the importance of establishing the framework structure first (basic skills illustrated in the counseling formula) before they can move toward conceptualizing a client with their theory of choice (see Figure 2). After counseling students have mastered basic skills, they can move to more advanced intervention techniques (e.g., empty chair, genogram). Mastery allows students to develop a new understanding through building upon different concepts to fit with the open umbrella graphic; this strategy also is known as concept management (Akinsanya & Williams, 2004).

The counselor’s job is not to make clients change; that is the client’s responsibility. Clients are the experts of their situations or issues, and it is up to them to determine what they are willing and capable to change. Before they can make decisions about change (Chg), they must first have insight (I) to understand that they have choices (see Figure 1). Before they develop insight (I), they initially must have an awareness (A) of what is creating their struggle. The counselor’s timing with active listening skills, appropriate confrontation and silence facilitates client awareness (A) and insight (I).

Clients work on the second line (A à I = Change), but the second line is ultimately facilitated by the first line (C + F = M), which is similar to the five stages of change presented by Evans et al. (2011, p. 292). Therefore, this formula indicates that the counselor’s work focuses on the first line and the client’s work focuses on the second.

The second line of the concept map formula also serves as a crosslink in one’s development from student to counselor. In making this transition in the professor–student relationship, the professor explores the student’s understanding by focusing on the first line of the formula, and the student struggles with personal and professional change in the second line of the formula. As student counselors map out their progress in a counseling session, they are simultaneously developing awareness (A) through the growth and practice of basic skills, which leads to insight (I) related to development of professional effectiveness in shaping the session. This process gives beginning counselors a sense of professional identity development and the ability to track progression at the top of the equation. Just as clients are ready for change when they develop awareness and insight, student counselors cannot include their theoretical orientation and techniques until they develop their own awareness in the therapy room and grasp the application of skills employed in the therapeutic session. Therefore, the client’s role in counseling also is the student’s role in professional development; and caution must be exercised not to initiate change too quickly with either the student or client, depending on how the formula is applied.

Counseling students often have heard from family and friends that they are great listeners; however, their sense of homeostasis is challenged when they sit across from clients while trying to master basic skills. They are anxious to jump ahead and learn to use techniques that are appropriate for their counseling theory of choice. Because counseling students jump ahead, they tend to overlook the importance of mastering fundamental skills. Since students have not mastered basic skills, they struggle to understand how theory and techniques work together to help clients. This situation can lead to ineffective use of both theories and techniques.

When the counselor moves too quickly, the client’s sense of balance is thrown off and resistance may occur because of low commitment or discomfort with change (Reiter, 2008; Wachtel, 1999). Resistance is the client’s attempt to return to a sense of homeostasis, even if homeostasis is not effectively meeting the client’s needs. MacCluskie (2010) posited that “the concept of homeostasis, borrowed from physiology, refers to the process by which an organism regulates its internal environment to maintain a stable, constant condition” (p. 212).

According to the formula, when the counseling process focuses on the cognitive content, resistance surfaces through the initial “storytelling” that clients offer. Beginning counselors often jump from hearing clients’ stories (cognition) to problem solving or advice giving (change) and encounter polarity or the yes, but type of resistance. Clients may agree with their counselors’ reflections, but respond with multiple excuses for why the suggestions or advice will not work (MacCluskie, 2010; Reiter, 2008; Wachtel, 1999). However, resistance or excuse making is the clients’ means of protection or attempt to return to a state of homeostasis when the counseling process threatens to push them to abandon their familiar life patterns or concepts of themselves, or push them too quickly to embrace change (Omer, 2000; Patterson & Welfel, 2000).

Basically, counselors forget to take their clients with them through the therapeutic process and must return to the beginning of the first line of the equation (C + F = M). As counselors work here, they must learn to trust the therapeutic process enough to allow clients to do their work on the second line (A promotes I, which facilitates Chg). Through clients’ responses and explorations, their awareness is raised, they gain insight and they are then empowered to make choices related to their personal change comfort level.

Two skills not included as part of the formula are confrontation and immediacy, because these advanced skills come later in the training process. Beginning counselors must first develop mastery of initial skills before they are ready to tackle confrontation and immediacy. While confrontation and immediacy may be powerful methods of intensifying emotions, they also may result in significant disengagement of the client if misused or if the timing is inappropriate (Cormier & Hackney, 2012; Evans et al., 2011; Smaby & Maddux, 2011).

Implications for Future Research

This counseling formula study supports the conclusion that a complex learning strategy, such as cognitive mapping, can be effective for counseling students of varied learning styles and cultures. In addition, evidence suggests that forcing students to use strategies that challenge their learning style preferences can be a beneficial attempt to increase their problem-solving skills (Kostovich et al., 2007). Further investigation of the influence of the counseling formula with beginning counseling students could provide counselor educators insight as to how their students are learning the counseling process using cognitive mapping. It is an organized method of teaching basic skills so that students do not find themselves overwhelmed with too much new learning to master at one time. Future research would be helpful to validate the general application of this formula and the umbrella concept when introducing beginning students to the basic tools of their future profession.

Conclusion

The simple images of a counseling formula and a symbolic umbrella help beginning counselors initially understand the interconnectedness of the different counseling skills of their new profession. However, this article is not suggesting that counseling is simplistic or that it does not utilize higher order skills and concepts. Counselor educators can use these symbolic representations as cognitive schemas to build upon students’ knowledge as they integrate practical application into their counseling sessions. Cognitive maps provide a way for counselor educators to see where students get stuck in the beginning counselor process, and provide a tool that allows a way of learning that is visual and communicative. This visual representation outlines and crosslinks the critical roles of the therapy process by connecting the communication and experiences of the student counselor to those of the client.

The student counselor stays at the top of the equation, while the client remains at the bottom. As student counselors become more seasoned, they also begin to experience personal and professional growth that results in their own awareness, insight and change; therefore, they experience crosslinking at the bottom of the equation that is similar to how clients begin to change. As clinicians gain experience, they move to a deeper understanding of how to use basic skills with theory, incorporated with existing intentional therapeutic interventions and techniques, in order to facilitate change for their clients. Through this process, clinicians come to fully appreciate both the therapeutic relationship and the counseling process.

Initial learning experiences in kindergarten are designed to help beginning students master simple, repetitive writing tasks. This initial learning experience can be compared to beginning experiences for master’s-level counselors through the effective utilization of initial basic skills linked in the counseling session. The formula and umbrella graphics can provide valuable visual tools to lay a solid foundation for the beginning counselor.

Utilizing the formula and umbrella graphics to gain an understanding of the application of basic skills is a valuable tool on the clinician’s lifelong learning journey to become a more effective counselor. When clinicians are “stuck” with a client, what better tools are within our grasp than to return to basic skills and use the formula? Basic skills are an integral part of the clinician’s toolbox, regardless of theoretical orientation or therapeutic interventions. These tools open clients’ awareness (A), promote insight (I), and unlock a myriad of options for clients to embrace (Chg) change (Asimakopoulou et al., 2012; Jacobs, 1994; Jacobs et al., 2012; Meier & Davis, 2011).

Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.

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Susan A. Adams, NCC, is a private practice counselor and supervisor in Denton, TX. Alice Vasquez, NCC, is a doctoral student at Texas A&M – Commerce. Mindy Prengler, NCC, is a counseling intern at Fine Marriage & Family Therapy, Plano, TX. Correspondence can be addressed to Susan A. Adams, 225 West Hickory Street, Suite C, Denton, TX 76201, drsadams@centurylink.net.