2018 Dissertation Excellence Award

2018 Dissertation Excellence Award

TPC received entries for the fifth annual Dissertation Excellence Award from across the United States. After great deliberation, the TPC editorial board committee selected Christopher T. Belser to receive the 2018 Dissertation Excellence Award for his dissertation, Predicting Undergraduate Retention in STEM Majors Based on Demographics, Math Ability, and Career Development Factors.

Dr. Christopher Belser is an assistant professor in the Department of Educational Leadership, Counseling, & Foundations at the University of New Orleans. He received his PhD in counselor education and supervision in May 2017 from the University of Central Florida, where he also served as an adjunct faculty member and a graduate teaching associate.

Dr. Belser’s research interests include P–16 career development initiatives in the areas of science, technology, engineering, and mathematics (STEM), as well as school counselor practice and preparation. He was a co-investigator with the NSF-funded UCF COMPASS Program and has also received research funding from the Louisiana School Counselor Association. He has written numerous articles and chapters on various counseling and career development topics and regularly presents at national and state counseling conferences. Dr. Belser holds service positions with several counseling organizations, serves on the editorial boards of two counseling journals, and is a National Certified Counselor.

Prior to beginning his doctoral work, Dr. Belser worked as a middle school counselor and as a career coach in various schools in Louisiana. He received both his MEd in school counseling and his BA in English (secondary education) from Louisiana State University.

TPC looks forward to recognizing outstanding dissertations like Dr. Belser’s for many years to come.

Read more about the TPC scholarship awards here.

2017 Dissertation Excellence Award

TPC received entries for the fourth annual Dissertation Excellence Award from across the United States. After great deliberation, the TPC editorial board committee selected Hannah E. Acquaye to receive the 2017 Dissertation Excellence Award for her dissertation, The Relationship Among Posttraumatic Growth, Religious Commitment, and Optimism in Adult Liberian Former Refugees and Internally Displaced Persons Traumatized by War-Related Events.

Dr. Acquaye is a first-year Assistant Professor of counseling at Western Seminary in Portland, Oregon. Some of the classes she has taught include: theories in counseling, group counseling, research and evaluation in counseling, tests and measurement in counseling, and family systems therapy.

Prior to her position at Western Seminary, she was a doctoral student in the University of Central Florida’s counselor education program. In August 2016, Dr. Acquaye graduated with a Ph.D. after defending her research on refugee trauma and growth. She obtained her master’s degree in Ghana, her home country, where she worked with young adults in schools and churches. Recognizing her inability to help refugees who kept coming to Ghana, especially when they entered the school system, Dr. Acquaye decided to pursue a terminal degree to help her educate more people about assisting this unique population.

Her research passion encompasses counselors and their collaboration to bring interventions to survivors traumatized by war and/conflict, e.g., refugees, dislocated and/or relocated individuals and/or immigrants. To help marry the research and clinical work, Dr. Acquaye is also doing her clinical work with Lutheran Refugee Services, Northwest, in Portland, where she serves both resettled refugees and mainstream clients with mental health challenges.

TPC looks forward to recognizing outstanding dissertations like Dr. Acquaye’s for many years to come.

Read more about the TPC scholarship awards here.

2016 TPC Outstanding Scholar Award Winner – Concept/Theory

Mehmet A. Karaman and Richard J. Ricard












Mehmet A. Karaman and Richard J. Ricard received the 2016 Outstanding Scholar Award for Concept/Theory for their article, “Meeting the Mental Health Needs of Syrian Refugees in Turkey.”

Dr. Mehmet A. Karaman is an Assistant Professor of counseling at the University of Texas Rio Grande Valley. Dr. Karaman has practiced in psychiatric hospitals, community mental health agencies, school districts and non-profit organizations. His research interests include instrument development and validation, cross-cultural studies (e.g., Turkey, Saudi Arabia, Mexico), counseling refugees, achievement motivation, and counseling children and adolescents. He is the past president of Texas Association for Humanistic Education and Development.

Dr. Richard J. Ricard is Assistant Dean and Professor of Counseling & Educational Psychology at Texas A&M University—Corpus Christi. He received his bachelor’s degree from the University of California, San Diego and his M.A. and Ph.D. from Harvard University in developmental psychology. He has been teaching in higher education for over 25 years. Dr. Ricard’s research focuses on program evaluation and implementation of evidence-based counseling interventions with adolescents in schools. His most recent teaching and research focus is on counseling interventions that emphasize mindfulness-based approaches (e.g., DBT, ACT, MBCT) that support counselor and client well-being.

Read more about the TPC scholarship awards here.

Meeting the Mental Health Needs of Syrian Refugees in Turkey

Mehmet A. Karaman, Richard J. Ricard

Movements such as the Arab Spring (as described by popular media) and recent regional conflicts have forced people to leave their homes and flee to other countries or regions. Syrian refugees are currently the second largest refugee group worldwide, with half of them resettled in Turkey. Turkish government and non-governmental civil organizations have mobilized efforts to address the immediate survival needs of these refugees such as food, shelter and other provisions. Despite efforts to manage the complexity of mental health and social service needs of forcibly displaced people, counseling services are still lacking. This expository article addresses the mental health needs of Syrian refugees and provides implications for counseling professionals working with displaced people from a crisis intervention approach built on principles and perspectives of humanistic mental health. In addition, programs of support, such as the Mental Health Facilitator program, are discussed.

Keywords: Syrian refugees, mental health, Turkey, displaced people, Arab Spring


The Arab Spring has affected many Arabic countries in the region and resulted in regime changes and general disruption in people’s lives (Khan, Ahmad, & Shah, 2014). The Arab Spring refers to a wave of revolutionary civil unrest, riots, demonstrations and protests in the Arab world that began in December 2010 in Tunisia, and spread throughout the countries of the Arab League and its surroundings (“Arab Spring”, n.d.). The Syrian Republic is embroiled in a civil war in which separatists have been protesting for more democratic rights and the imposition of a civilian government. The region has been further destabilized by the conflict surrounding ethnic origin, and the political and religious activities of the Islamic State of Iraq and Syria (ISIS).


Approximately 6 million people have taken refuge in Turkey, Lebanon, Jordan, Iraq and Egypt since the Syrian conflict began in 2011 (United Nations High Commissioner for Refugees [UNHCR], 2016). According to the UNHCR (2016), the Republic of Turkey (Turkey) has accommodated the largest number of Syrian refugees in the region. The Turkish government quickly took the necessary steps, such as opening the border and providing food and shelter, after the first group of Syrian refugees entered Turkey on April 9, 2011. To date, there are roughly 2.8 million refugees living in camps and urban areas; half of these refugees are children (UNHCR, 2016). The majority of refugees (90%) live outside of camps and are surviving under challenging circumstances compared to the refugees who live in camps. Refugee camps offer health care, education, food, security and social services. However, refugees who live outside of camps have limited access to information and public services such as education and health care.


Syrian refugees are enduring daily challenges to physical and mental survival. In addition to the extreme needs for physical and nutritional interventions, mental health professionals recognize the urgent need for counseling services based on widespread documented reports of refugees’ exile experiences and exposure to multiple sources of trauma (Sirin & Rogers-Sirin, 2015). This crisis has resulted in a population of displaced people suffering from a number of mental health issues (Alpak et al., 2014; Betancourt et al., 2015; Clarke & Borders, 2014; Özer, Şirin, & Oppedal, 2013). For example, Önen, Güneş, Türeme, and Ağaç (2014) conducted a quantitative study on Syrians who resettled in refugee camps. The results indicated that 19% of refugees reported high levels of anxiety and 9% experienced high levels of depression. In a recent study, Alpak et al. (2014) reported that approximately one third (33.5%) of Syrian refugees showed symptoms consistent with a diagnosis of post-traumatic stress disorder (PTSD).


The fact that many of the displaced Syrians are especially vulnerable children living far from their homes, cultures and countries further highlights the magnitude of the crisis (Özer et al., 2013). Recent reports indicate that up to 50% of the Syrian refugees are children suffering from exposure to severe traumatic events at rates higher than their adult counterparts (Sirin & Rogers-Sirin, 2015). Özer et al. (2013) reported that 74% of Syrian children in a refugee camp have experienced the loss of a family member or a loved one, and 60% of children felt their lives were in danger. These self-reports of distress and concern are consistent with another recent study of 8,000 displaced Syrian children who reported constant fears (15.1%) and suicidal thoughts (26%; James, Sovcik, Garoff, & Abbasi, 2014).


Several indicators suggest that the severity of the current Syrian refugee crisis is unprecedented. A recent meta-analysis compared the relative rates of mental health disorders between refugees from different world regions and ultimate country of relocation (Fazel, Wheeler, & Danesh, 2005). Fazel et al. (2005) found that while up to 10% of refugees who relocated in Western countries experienced symptoms of PTSD, major depression and generalized anxiety disorder, the frequency of these diagnoses is significantly greater among the current Syrian refugee population (Alpak et al., 2014; Önen et al., 2014). For example, Syrian refugees who resettled in Turkey had a higher incidence of mental health disorders when compared to refugees from Southeast Asia, former Yugoslavia, and Central America who settled in Western countries (i.e., United States, Australia or Canada) collectively referred to as the Organization for Economic Cooperation and Development.


Recognizing the severity of the crisis, Turkey has initiated legal reform, established programs and practices, and requested humanitarian assistance from the international community to help manage the influx of Syrian refugees (Özden, 2013). Turkish government and non-governmental civil organizations have mobilized efforts to address the immediate survival needs of refugees, such as providing food and shelter. Despite these efforts, the available resources, including the number of counselors and other qualified mental health professionals, are inadequate to deal with the constant flow of Syrian refugees (Sahlool, Sankri-Tarbichi, & Kherallah, 2012). The vestiges of war have resulted in an increase in the prevalence of a number of psychosocial stressors and disorders (e.g., PTSD) as well as total desolation of social networks of family, friends and loved ones (Akinsulure-Smith & O’Hara, 2012). These challenges underscore the complexity of mental health and social service needs of forcibly displaced people in the region (Alpak et al., 2014).


This article highlights the challenges faced by the Turkish government related to a humanitarian response to the Syrian refugee crisis. Suggestions are provided for designing appropriate responsive counseling services for refugees from a diversity of sociocultural and geopolitical contexts. Principles and best practices (grounded in humanistic counseling theory) for addressing the mental health needs of diverse displaced people are discussed. Opportunities for generalization and specific cultural applications and adaptations are presented as well.


The Syrian Culture


Syria is located in Southwestern Asia at the eastern end of the Mediterranean Sea. It has its longest border with Turkey on the north, and is bordered by Israel and Lebanon on the west, Iraq on the east, and Jordan on the south. The majority of Syria’s population consists of Arabs (90.3%) and the remaining 9.7% consists of Kurds, Armenians and others (The World Factbook, n.d.). Religiously, Syria is a mosaic society. The vast majority of the population (87%) consists of Muslims (74% are Sunni and 13% are Alawi, Ismaili and Shia). Christians (Orthodox, Uniate, and Nestorian) are the largest single minority religious group (10%), and 3% of the population consists of Druzes (The World Factbook, n.d.). Before the beginning of the civil conflict (between the Syrian government and groups of citizens), positive intergroup relationships, for example between Christians and Muslims, were readily observed. However, the current situation of intergroup relationships is unknown since the political equilibrium has changed and continues to change rapidly.


Adherence to religious principles and cultural edicts are fundamental to a typical Syrian’s daily life. Islamic creeds and beliefs, such as Iman (faith) and Qadar (destiny), are elemental and strictly proscriptive of Muslim lifestyle (Eltaiba, 2014). Accordingly, traditions and customs associated with family life (relationships, marriages and future plans) are rooted in cultural and religious traditional practices. Family life is the center of Syrian social structure and extended families are the most common family type (Mahdi, 2003). Intermarriages between ethnic groups, religions and social classes are rare. As an authority figure, the father or the eldest man (grandfather) in the household has the power and is the foundation of a patriarchal structure, giving an advantage to males (Mahdi, 2003).


Addressing the Needs of the Syrian Refugees


Turkish officials have utilized a physiological and psychological needs-based approach (Inter-Agency Standing Committee [IASC], 2007) in the planning for a response to the refugee crisis. The approach has largely been adapted from humanitarian organizations (e.g., Red Crescent, UNHCR) that provide relief, crisis interventions and emergency services. Counseling services are usually not the immediate priority of refugees; most refugees will not seek available counseling or even be able to take part in counseling activities if they do not have a roof over their heads or food in their stomachs and are struggling to survive (International Federation of Red Cross and Red Crescent Societies [IFRCRCS], 2009). Consistent with Maslow’s (1943) original theory, crisis intervention efforts need to address the most immediate needs that threaten basic survival (e.g., hunger, safety) first. Once these basic needs have been met, individuals can address other difficulties associated with the experience of trauma (IFRCRCS, 2009). In this respect, the crisis level and needs of refugees determine the priority of counseling and psychosocial support services. National and international mental health crisis intervention organizations (IASC, 2007; IFRCRCS, 2009), such as the Turkish Red Crescent organization, have adopted IASC guidelines (2007) and the recommended four-level approach, which is described below, to assess the urgency of needs for refugees and victims of natural disasters.


Level 1: Basic Needs and Security

     Syrian refugees are in need of basic services such as shelter, nutrition, education, medication and health care services. Approximately 1.4 million Syrian refugees are children (Orhan & Gündoğar, 2015; UNHCR, 2016), and the United Nations Children’s Fund (UNICEF; 2014) has reported that these children are at risk of being a “lost generation.”  Moreover, security is a source of distress because of recurring aggression towards refugees who live out of the camps. These events continue along the border with Turkey. For example, a car bombing killed 57 refugees and wounded at least 80 Syrians near a border crossing between Turkey and Syria (UNICEF, 2014).


Level 2: Situation of the Community and Family Support

There is a sense of distrust within the Syrian refugee community that is rooted in the ongoing conflict in Syria (Chammay, Kheir, & Alaouie, 2013). Displaced persons from both sides of the conflict are often resettled together, despite differing political affiliations. Refugee families are struggling to survive in the midst of widespread fragmentation. For instance, Özer et al. (2013) reported that 74% of children in the Islahiye refugee camp had experienced the loss of a family member, affecting the well-being of the whole family.




Level 3: Focused, Non-Specialized Counseling Support

According to the Disaster and Emergency Management Presidency (DEMP; 2013), 51% of Syrian refugees report a need for some form of psychological support. In the same report, approximately 26% of refugees indicated dissatisfaction with the mental health care they received. In parallel with this finding, Chammay et al. (2013) stated that Syrian refugees felt disrespected by the mental health professionals.


Level 4: Specialized Counseling Services

     In Turkey, counseling services are different than those in the United States and other developed countries. Turkish counseling services have focused exclusively on school settings and most counselors work as school counselors (Korkut, 2007; Stockton & Yerin Güneri, 2011). When compared to the United States, there are no specializations in the counseling education system in Turkey, such as clinical mental health, career counseling and addictions counseling. In Turkey, mental health services are provided within the medical field; thus, the majority of professionals who work in mental health have consisted of psychiatrists and nurses (Yilmaz, 2012). This situation has affected the availability of counseling and mental health services for Syrian refugees seeking assistance. The efforts of DEMP, Red Crescent, UNHCR, and other non-government and non-profit humanitarian organizations (e.g., Humanitarian Relief Foundation, Support to Life) are not enough to meet the counseling and mental health needs of Syrian refugees.


Mental Health Needs


Empirically validated research on the mental health needs of the Syrian refugees in Turkey and other countries (e.g., Lebanon) is limited due to a lack of focus on the assessment procedures and diagnostic reporting (Chammay et al., 2013). As documented by previous reports of forcible displaced peoples, Syrian refugees are at especially high risk for mental health problems as well as social and physical concerns and uncertainty about the future and current situation in Syria. Individual accounts of extensive violence, death and war illustrate the distress of refugee life at the personal level. For example, the following illustrates one refugee’s account of witnessed chaos in Syria:


The soldiers were gathering men in some areas. They interrogated a father, “Which one is your son?” the soldier demanded. The desperate man pointed out his son. The soldier then cut the man’s son’s throat first, then they shot the father. They were killing and burning so many people that the smell of burning bodies spread through the entire city, like a blanket of death smothering any hope of survival. (Korucu, 2013, p. 90)


This story highlights not only the experience of physical pain, but also fears, losses and spiritual wounds associated with protracted exposure to physical and emotional trauma. Although all refugees did not experience traumatic events or witness a massacre, they fled with other refugees who experienced loss, trauma and torture. The stories spread to others in camps and in the media, and as a result many fled to other countries to protect themselves and their loved ones.


Each refugee client has different needs, and “not every refugee who seeks counseling will require individual therapy for psycho-emotional issues. Counselors should not assume simply because of a traumatic background, intense loss, and other aspects of refugee experience that a refugee is necessarily psychologically impaired” (Baker, 2011, p. 122). In addition to basic physical needs, counselors need to be aware of and focus on the wellness and psychological needs of refugees. Research on well-being (Davidson, Murray, & Schweitzer, 2008) has highlighted the fact that health and wellness is indicated by more than a “lack of diagnosis” (Savolaine & Granello, 2002). There are common concerns that affect refugees in general. For instance, distress about the future, housing, employment, and separation from the family and the culture of the host country or community are predominant issues in refugees’ lives. These factors affect their emotions and holistic wellness (Clarke & Borders, 2014; Tempany, 2009). There are specific situations that affect the mental health of Syrian refugees. First, 83% of Syrian refugees have experienced a traumatic event (Chammay et al., 2013). The intensity of the experience and duration of exposure may affect the level of mental health. Stories and experiences of refugees who were exposed to the traumatic events can frighten other refugees who did not experience a traumatic event, triggering anxiety and stress. Second, unmet physiological needs may exacerbate feelings of insecurity and affect healthy psychological responses. Moreover, refugees’ lack of personal awareness of their own mental health needs can affect help-seeking behaviors. Third, there may be acculturative stress stemming from cultural differences and adaptation to the host culture, which can adversely affect mental health factors after immigration. Specifically, high risks exist for children who lost one or both of their parents in the war. Last, hearing about and seeing people continuing to die in the conflict through news and social media can increase or sustain depression and PTSD symptoms (Alpak et al., 2014).


These compounding mental health issues exacerbate the daily struggles faced by Syrian refugees and underscore the need for mental health intervention (Alpak et al., 2014; James et al., 2014; Özer et al., 2013). One of the most important counseling services would be multicultural transition and adaptation to a new (even if only temporary) living situation.


The Availability of Multiculturally Competent Mental Health Counselors

The impact of a counselor’s awareness of personal cultural values and a client’s worldview is foundational to multicultural counseling competence (Arredondo et al., 1996). We believe that mental health professionals in Turkey will be better able to provide culturally sensitive counseling support to refugees when they make efforts to understand and appreciate the customs and traditions of their Syrian clients (Arredondo et al., 1996). Despite the proximity and often shared religious ideology, considerable differences between Turkish and Syrian citizens (e.g., language, beliefs, cultural practices) may influence the quality of social services refugees receive in their host country. Although Turkey is the neighbor of Syria and shares many cultural and historical ties, a healthy process of cultural transition and adaptation is needed for refugees. More counselors, mental health facilitators (MHFs) and interpreters are needed to provide adequate mental health services, guide the refugee community in meeting their physiological needs, and inform the host culture to decrease prejudice.


Barriers, Challenges and Implications for Counseling


Counseling professionals need to be mindful of the diversity of displaced people. The majority of Syrian refugees fleeing to another country for survival bring different political experiences, levels of education, religions, ethnicities and levels of income to the resettled environment (DEMP, 2013). Counselors may face some challenges and barriers to providing services when working with this unique population. These challenges may include, but are not limited to, language, culture and dependence on Western-based counseling interventions. For example, some refugees might not attend group counseling if they are assigned to the same group with refugees who have different religious beliefs or ethnicity (Eltaiba, 2014). In such cases, counselors’ sensitivity and skills for addressing issues of cultural heritage and historical background of culturally different clients can transform disadvantages into advantages (Sue, Arredondo, & McDavis, 1992). There are effective resources and handbooks that provide detailed guidelines for working with refugees and forced migrants (Hinkle, 2014; IFRCRCS, 2009; UNHCR, 2013). A counselor can create his or her own guidelines for specific or general challenges of working with a refugee population. Specifically, when counselors work with Syrian refugees to create treatment plans, they should consider clients’ culture, religion, ethnicity, worldview and language in order to be more effective.


Language Barriers

The majority of Syrian refugees have resettled in Jordan, Lebanon, Iraq, Egypt and Turkey (UNHCR, 2016). While Syria, Jordan, Lebanon, Iraq and Egypt are Arabic countries and have a common culture and language, the majority of people in Turkey have a Turkish heritage and speak Turkish. Furthermore, the availability of Arabic-speaking counselors in Turkey is limited. Government organizations and social service agencies have experienced difficulty finding bilingual personnel as well (e.g., medical doctors, counselors; DEMP, 2013). Providers have responded by employing language interpreters to facilitate counseling contacts with refugees. Language barriers may create trust issues due to the existence of a third person in the session and it may be difficult for the counselor to establish rapport with the refugee client (Akinsulure-Smith & O’Hara, 2012; Baker, 2011). In this respect, several best practice approaches for maximizing the beneficial usefulness of interpreters are warranted. First, counselors may need to meet with the interpreter to explain confidentiality and the goals of the counseling interview; discuss the interpreter’s cultural background and cultural expectations; explain the need for detailed translation in the assessment; and discuss seating positions in the session (Baker, 2011; Paone & Malott, 2008).
When counselors work with interpreters they also need to consider interpreters’ citizenship status. Interpreters who are themselves refugees may be vicariously vulnerable to experiences reported by clients. Therefore, a program of careful screening, ongoing training, supervision and support for interpreters is vital (Miller, Martell, Pazdirek, Caruth, & Lopez, 2005). Programs of support, such as the National Board for Certified Counselors’ (NBCC) Mental Health Facilitator (MHF) program (Hinkle, 2014), would be helpful for Turkish counselors and interpreters. The MHF program covers the global aspects of community-based mental health training. The MHF initiatives are designed to empower local community members with skills for providing basic mental health services to people who are in crisis (Hinkle, 2014). By working with local volunteers, the MHF programs bridge the gap created by limited access to mental health services provided by mental health professionals, such as professional counselors, psychiatrists, social workers and clinical psychologists. The MHF curriculum includes implementation strategies for nonclinical, basic assessment, social support and referral services (Hinkle, 2014). While the current MHF curriculum and materials are available in the Arabic language, recent reports indicate that materials have not yet been translated to Turkish. Access to culturally sensitive training programs like MHF may be a crucial element to increasing the impact of mental health initiatives targeting refugee populations. Turkish governmental authorities and non-profit organizations would be wise to take immediate action with NBCC to adapt this program to Turkish.


Language immersion efforts are one promising approach to minimizing the impact of linguistic barriers. For example, approximately 87% of the Syrian refugees in Turkey reported that they wanted to learn Turkish (DEMP, 2013). The government and non-profit organizations have Turkish courses for refugees in the camps and cities. Counselors may use these classes as one of their referral sources. The classes also give an opportunity for clients to attend an activity, engage in the society, meet with new people from their own cultures and communicate with local residents.


Challenges Due to Refugee-Host Community Relations


A rapid influx of migrants can place considerable stress on the fiscal and emotional resources of the host country (Orhan & Gündoğar, 2015). The current Syrian refugee crisis has shifted from a humanitarian to a political crisis for other countries (e.g., Germany, Sweden, France; Hebebrand et al., 2016). Many refugees who live in Turkey are trying to fly to other European countries. However, politicians of those countries are not willing to accept refugees because of security, resources and possible dissent of their citizens (Hebebrand et al., 2016).


Although Turkey and Syria have longstanding historical ties and similar cultural and religious orientations, refugees will almost certainly experience acculturative stress, oftentimes as a result of negative reception from the host country (Betancourt et al., 2015). For instance, residents of the Gaziantep province, which has the second highest number of Syrian refugees in Turkey, protested against refugees and initiated physical attacks on them. The conflict increased the tension in the city and forced authorities to resettle some refugees in other provinces.


Bektaş (2006) has indicated that attempts at a multicultural curriculum in Turkish counseling education programs are not enough, and there is not a current mechanism or system (e.g., CACREP) to promote multicultural counseling competencies among Turkish counselors.  Governmental and non-profit organizations need to consider diversity and ethical considerations when recruiting counselors for counseling and mental health services. The Turkish government’s policies toward the ongoing situation in Syria might polarize the government officials and mental health professionals who work with the Syrian refugees. At this point, counselors should be aware of their own personal views, biases and political ideas. They should be able to focus on their role as counselor rather than as resident or citizen.


With respect to provision of clinical mental health services, tensions between residents and refugee groups may interfere with effective receipt of counseling interventions by refugees.  These events might cause mistrust towards counselors since they can be seen as part of the system, members of the host culture or representatives of the authorities (Vanguard, 2014). Holistic and advocacy-based services are more beneficial for refugees to cope with cultural difficulties (Baker, 2011; Clarke & Borders, 2014). These services include psychosocial support, counseling, referral sources, education and programs for the host community. Furthermore, counselors can provide additional services, which are not listed here, based on the needs of refugee clients.


Cultural and Spiritual Challenges

Syria represents an Eastern culture with dominant collectivist characteristics (Samovar, Porter, & McDaniel, 2010). The religion of Islam plays a role not only in individuals’ personal lives, but also in social life and society. Religion and spirituality are a way of life for Muslims across different cultures (Eltaiba, 2014). Religion determines the relationship between men and women, social roles, laws of inheritance, what people can and cannot eat, childcare, marriage and more. In addition to the culture of religion, traditions guide people’s lives as well. As mentioned before, the Syrian culture has a patriarchal structure. In this situation, men have more rights and freedom than women (Mahdi, 2003). For example, this patriarchy can create problems when counselors plan for group counseling. It can be difficult for women to talk about or share their problems in front of men. In this respect, dividing groups based on gender can be more effective.


In such cases, religion and spirituality can be explored in individual counseling sessions.  Research has shown that religious coping can be used effectively by refugees (Clarke & Borders, 2014). For example, a Muslim refugee client might think that he or she deserves the current circumstances and whatever happens is Allah’s will. This belief represents the basic idea of Qadar – destiny or fate – and should be addressed carefully by the counselor because Qadar includes the individual’s will and belief that everything comes from Allah/God, and since refugees are under stress they can give up all the responsibility to Allah or God. A holistic approach that focuses on both the individual’s and society’s values and needs should be implemented since culture and religion provide significant means for coping.


Challenges With Counseling Interventions

Many migrants and forced refugees are not familiar with the concepts of counseling, which might seem strange to them (Akinsulure-Smith, 2009; Akinsulure-Smith & O’Hara, 2012). Refugees need to understand the services available in order to benefit maximally from them. The government and humanitarian agencies need to use terms that make sense for Syrians. When organizations prepare brochures, handbooks, reports and name plates, they should explain available mental health and counseling services, define counselor, and explain their services.  Most Turkish counselors who work with Syrians were educated in Turkish counseling programs, which were modeled on U.S. programs and included Western-based counseling theories (Mocan-Aydin, 2000). This Western-based education and theories might decrease the effectiveness of counseling and challenge counselors because Syrians come from an Eastern culture. Since they have moved to a new culture, been separated from families, and experienced pressure and persecution, many refugees do not understand their new culture or know where to find help. In this respect, a group of Syrian mental health facilitators trained with the NBCC MHF program can be a valuable resource for working with this population (Hinkle, 2014). The inclusion of trained community volunteers will likely increase refugees’ access to mental health services while simultaneously decreasing the work load of professional counselors.




Over 2.8 million Syrian refugees have resettled in Turkey in the period of 2011 to 2016 (UNHCR, 2016). As the refugee population continues to grow, host nations will need to prepare a systematic response to this continuing humanitarian crisis in ways that support the basic human needs of forcibly displaced people. The Turkish government has responded to the presence of Syrian refugees with interventions that support basic survival needs (i.e., food and shelter). The availability of mental health and social services for refugees is limited and remains a focus of humanitarian assistance. Counselors should be cognizant of the traumatic experiences refugees often endure in the context of displacement and ongoing conflict. Counselor training and facilitation of community-based mental health advocates such as those provided by MHF can increase the impact of available counseling interventions for refugees. In addition, the IASC four levels crisis intervention approach, which is used by the Turkish Red Crescent organization, can be beneficial to address traumatic experiences and the needs of refugees.



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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Mehmet A. Karaman is an Assistant Professor at the University of Texas Rio Grande Valley. Richard J. Ricard is a Professor at Texas A&M University-Corpus Christi. Correspondence can be addressed to Mehmet A. Karaman, EDUC 1.642, 1201 West University Dr., Edinburg, TX 78539-2999, Mehmet.Karaman@utrgv.edu


Violence and Residual Associations Among Native Americans Living on Tribal Lands

Adam Hardy, Kathleen Brown-Rice

The article reviews the empirical literature regarding exposure to violence among Native Americans living on tribal lands. The prevalence of various types of violence experienced by this population is identified. Predictive characteristics correlated with higher rates of violence among Native Americans living in tribal communities have been reported by researchers to include socioeconomic status, unemployment, gender, cultural affiliation, substance abuse, relationship status, history of violence exposure, and adverse childhood experiences. Residual associations include PTSD, anxiety, depression, chronic pain, substance abuse, promiscuity, suicidal ideation, communal deterioration, and cardiovascular disease. Barriers for addressing mental health needs in this population, implications for mental health counselors and directions for research are provided.


Keywords: Native Americans, tribal lands, violence, predictive characteristics, residual associations


The treatment of Native American populations has not been a traditional area of focus among mental health researchers (Matamonasa-Bennett, 2013). However, a push for increased knowledge in the effective treatment of this population has led to an influx of empirical attention in the past few decades. The National Congress of American Indians declared violence against Native Americans, particularly those living on tribal lands, as the most critical issue faced by Native Americans (Matamonasa-Bennett, 2013). Complicating the interpretations of the subsequent studies, Evans-Campbell (2008) concluded significant differences between Native Americans living on tribal lands and Native Americans living in urban areas. It is critical that counselors be cognizant of such within- group differences (Brown-Rice, 2013). Research efforts related to Native American populations living in tribal communities have predominately focused on exposure to violence. In order to bridge the gap in understanding how violence impacts Native Americans, the current review addresses the prevalence, predictive characteristics and residual associations related to violence among Native American men and women living on tribal lands. Moreover, the barriers to addressing mental health treatment among this population are discussed. Implications for counselors and directions for research are provided.


Violence and Mental Health Issues for Native Americans


Violence can consist of physical, sexual and emotional assault (Watts & Zimmerman 2002). Many acts of violence can be characterized as a combination of these categories, such as a sexual assault that also produces physical harm to the survivor. Physical violence can include assault, neglect of basic needs (which is most common among children), exploitation of labor and false imprisonment. Sexual violence includes rape, fondling, genital mutilation and sex trafficking (Watts & Zimmerman, 2002). Emotional violence includes isolation, verbal abuse, economic abuse, coercion, threats and intimidation (Pence & Paymar, 1993). Because violence is often conceptualized as a means to gaining or maintaining power and control over others, a survivor of violence is often victimized by those closest to him or her, such as a family member or friend (Watts & Zimmerman, 2002).


     Post-traumatic stress disorder (PTSD) has been associated with exposure to physically, sexually and emotionally violent experiences (Ford, Grasso, Elhai, & Courtois, 2015). Traumatic stress symptoms are often more complicated to treat in circumstances when an individual has been exposed to prolonged or repeated violence. Furthermore, these symptoms are more likely to develop when survivors of violence feel a sense of betrayal from the perpetrator, which is often reported by those who experience sexual assault and domestic abuse (Ford et al., 2015). Researchers have concluded that these issues are more prevalent among Native Americans living on tribal lands (Malcoe, Duran, & Montgomery, 2004; Yuan, Koss, Polacca, & Goldman, 2006), which may suggest a higher likelihood for the development of PTSD when compared to other populations.


Although PTSD is the mental health disorder most often associated with individuals who experience violence, depression (Cascardi, O’Leary, & Schlee, 1999) and anxiety (Pico-Alfonso et al., 2006) symptoms have been highly correlated to violence exposure. Clearly, those who survive violence are at high risk of developing mental health symptoms and can benefit from professional intervention. However, the experiences of Native Americans related to violence are not likely to be completely congruent to other populations (Sue & Sue, 2012). For this reason, it is crucial for counselors to gain increased competency in the unique factors impacting the Native American community in order to provide effective care.


Violence Against Native American Women


United States legislators acknowledged in the 2005 Violence Against Women Act (VAWA) that Native American women living on tribal lands were a particularly marginalized population (Crossland, Palmer, & Brooks, 2013). VAWA mandated that several governmental organizations begin a series of research efforts in order to better understand the prevalence and residual consequences experienced by this population when violence was present (Crossland et al., 2013). Bryant-Davis, Heewoon, and Tillman (2009) concluded that the studies succeeding VAWA indicated that violence against women had significantly decreased in the 10 years preceding the studies for every population except Native American women. These researchers also concluded that Native American women living on tribal lands account for the highest rates of exposure to violence compared to any other population. Despite these conclusions, Matamonasa-Bennett (2013) reported that Native American women continue to be underrepresented in research regarding violence against women.


Prevalence of Violence Against Native American Women

Determining the precise prevalence of violence among Native American women living on tribal lands is a complicated endeavor. There can be substantial differences between communities, leading to frequent misinterpretation in the results of research (Yuan et al., 2006). It is common that researchers report the prevalence of violence among Native Americans, even though the results of their studies accounted for the prevalence among a specific tribe. For this reason, it is important not to make generalizations regarding reports that do not expand to various regions by examining the methodological decisions of the researchers in order to better interpret the results (Gone, 2010). In response to the need for clarity on the prevalence of violence in tribal communities, Oetzel and Duran (2004) concluded that many researchers asked vague questions and excluded common types of physical violence, prompting them to investigate exposure to violence among Native American women by asking a wider range of specified questions. They determined that women in tribal communities reported the prevalence of violence exposure at rates ranging from 46–91%. They compared these results to non-Native populations, which had previously reported prevalence rates ranging from 7–51%. Similarly, Wahab and Olson (2004) examined the prevalence of physical violence among Native American women living on tribal lands while accounting for vast differences between tribes. These researchers concluded that this population experienced higher rates of physical violence than women of any other ethnicity.


While researching violence among Native American women, many researchers have focused on domestic violence. In a study spanning 12 distinct tribal communities, researchers reported that 58.7% of Native American women had been victims of domestic violence, resulting in severe physical trauma in 39.1% of these women (Malcoe et al., 2004). Hart and Lowther (2008) reported domestic violence incidents had increased each of the past 10 years prior to their study, indicating that this issue is escalating in tribal communities. Moreover, Native American women have reported higher levels of re-victimization than other female populations (Urquiza & Goodlin-Jones, 1994). L. Jones (2008) concluded that Native American women living on tribal lands found it difficult to leave violent relationships due to communal feedback which encourages victims to protect their abusers. Because Native American women are more likely than other women to be recurrently assaulted, there may be implications for the development of complex traumatic stress symptoms (Ford et al., 2015).


Sexual assault also appears to be a common form of violence experienced by Native American women. Prevalence rates of rape among this population have been reported as high as 34.1%, which is nearly twice the rates among other women in the United States (Tjaden & Thoennes, 2000). Behaviors of perpetrators of sexual assault on tribal lands also have been studied among researchers. When surveyed about sexual assault history, Native American women living in tribal communities have reported male relatives as the most often cited perpetrator of sexual assault, accounting for 55% of the incidents (Yuan et al., 2006). Significant percentages of perpetration of sexual assault also have been attributed to romantic partners (46%), acquaintances (29%) and strangers (28%). The likelihood of developing complicated traumatic stress symptoms may be increased due to the high frequency of sexual assault of Native American women by individuals who are familiar to them (Ford et al., 2015). Moreover, it appears that once a Native American woman living on tribal land is exposed to sexual violence, the likelihood of subsequent exposure is high. The recurrence of sexual assault among this population has been reported to be as high as 79% (Roodman & Clum, 2001).


Predictive Associations of Violence Against Native American Women

Malcoe, Duran, and Ficek (2002) concluded that socioeconomic status is a significant predictor of exposure to violence among Native American women living on tribal land. Specifically, women who have reported low socioeconomic characteristics are two and half times more likely to be exposed to physical violence (Malcoe et al., 2002; Oetzel & Duran, 2004). Specifically, it was reported that Native American women living on tribal lands who were receiving governmental financial assistance were nearly two and a half times more likely to report exposure to physical violence. According to the United States Census Bureau (2014), less than half of the residents of the Pine Ridge reservation in South Dakota were employed between 2010 and 2014. As a result, 52.2% of those living in this area were below poverty standards, which is well above the national average of 14.8%.


     Native American women living on tribal lands with substance abuse issues are at a higher risk for exposure to both physical and sexual violence (Yuan et al., 2006). Substance abuse issues among individuals close to Native American women have been reported to predict exposure to violence. Native American women with alcohol abuse issues, for example, reported significant levels of exposure to domestic violence (Yuan et al., 2006). Furthermore, Native American women have reported heavy alcohol use by 62% of their perpetrators, compared to 42% from women of other ethnic backgrounds (Ferraro, 2008). There is evidence to suggest that Native American women living on tribal land who identify with traditional Native American culture are less likely to be associated with substance abuse and related physical violence (Whitbeck, Adams, Hoyt, & Chen, 2004). Conversely, Native American women living on tribal land who report higher associations with traditional Native American culture have reported increased frequency of exposure to sexual violence (Yuan et al., 2006). However, increased focus on traditional Native American culture could be a coping mechanism used by women following victimization, potentially making cultural affiliation a residual effect of violence.


When considering sexual violence, the factor most predictive of exposure in Native American populations has been concluded to be gender (Yuan et al., 2006). Both Native American men and women are sexually assaulted, but Native American women report sexual assault at rates 14 times higher than males (Yuan et al., 2006). The relationship status of women living on tribal lands also has been correlated to exposure to sexual violence. Women engaged in cohabitating relationships and women separated and divorced were concluded by researchers to be at a higher risk for sexual violence (Bryant-Davis et al., 2009). Moreover, Bryant-Davis and Ocampo (2006) postulated that Native American women are sexually assaulted at higher rates than women of other ethnicities due to systematic eroticization, devaluation and objectification by American culture.


     Yuan et al. (2006) reported that Native American women living on or near tribal lands who experience emotional abuse as children report significantly higher rates of sexual violence exposure as adults. Similarly, women in this population who have survived sexual and physical abuse before the age of 18 are more likely to be raped in adulthood. Because a history of emotional, sexual or physical abuse appears to significantly contribute to the predictability of future exposure to violent traumatic stressors, increased attention on providing interventions to young Native American populations may prove beneficial for prevention efforts (Yuan et al., 2006).


Residual Associations of Violence Against Native American Women

Arbuckle et al. (1996) concluded that Native American women are three times more likely to be murdered than Latino and White women. Hence, death is a relatively common residual association to violence among this population. Witnessing homicide also can be a form of exposure to violence. When homicide occurs, there are often secondary victims seeking mental health services. Family and friends of a victim of homicide within the Native American population often report cognitive patterns of self-blame, which exacerbates mental health symptoms (Weinberg, 1994).


Native American women exposed to physical violence have reported high levels of traumatic stress symptoms (B. Duran et al., 2009). In a study that surveyed 3,084 Native Americans living on tribal lands across the United States, women reported PTSD symptoms with a frequency twice the rate of men (Buchwald, Goldberg, Noonan, Beals, & Manson, 2005). It was concluded that 16% of women living on tribal lands met the criteria for PTSD, which is 6% higher than the national average for women (Ford et al., 2015). Exposure to violence on tribal lands also has been associated with increased likelihood to develop mood disorders, anxiety disorders (B. Duran et al., 2009) and chronic pain (Buchwald et al., 2005).


The relationship between exposure to violence in tribal communities by Native American women and mental health disorders was examined by Oetzel and Duran (2004). These researchers concluded that physical injuries and medical assistance on tribal lands were highly correlated with symptoms of depression and that increased exposure to violence appeared to lead to negative sociological effects such as unemployment. Oetzel and Duran theorized that exposure to physical violence on tribal lands could be directly linked to chronic pain and psychological symptoms which limit the capacity for Native American women to change their environment when desired.


It is common that persons exposed to violence display high-risk behaviors, including substance abuse and sexual promiscuity (Hobfoll et al., 2002). It is believed that these behaviors can be conceptualized as a means of coping with traumatic stressors (Ford et al., 2015). Substance abuse, which has been identified as a predictive factor to physical violence exposure, also appears to be a residual association. Saylors and Daliparthy (2005) concluded that Native American women often use alcohol and illicit drugs in order to numb cognitive and emotional reactions to physical and sexual violence. Furthermore, among Native American women living in tribal communities, those with a history of exposure to violence are five times more likely to contract sexually transmitted infections when compared to women with no history of exposure to violence (Hobfoll et al., 2002). As a result, this population is more likely to contract HIV than women in other communities. When the spread of sexually transmitted infections is intentional or the risks are disregarded by carriers, it can be conceptualized as sexual abuse, even when sex is consensual. When considering the spread of HIV, this act can be criminal (Hobfoll et al., 2002).


Despite the high rates of sexual assault victimization that have been reported by Native American women living on tribal lands, residual effects of exposure to sexual violence have not been a major focus by researchers (Bryant-Davis et al., 2009). However, there have been several associations that have been linked to rape. Similar to what researchers have concluded from studying the effects of exposure to physical violence, researchers have concluded that Native American women living on tribal lands who reported a history of sexual violence victimization display high frequencies of symptoms that meet the criteria for PTSD and other anxiety disorders (Bryant-Davis et al., 2009). Perhaps related to this phenomenon is the research indicating that this population has reported high levels of suicidal ideation and more frequent suicidal attempts than women in other communities following sexual violence exposure (Bohn, 2003). Among Native American women who attempted suicide in one tribal community, 87% reported exposure to some level of sexual violence and 59% reported exposure to rape (Bohn, 2003).



Violence Against Native American Men


     A review of the literature on violence experienced on tribal lands reveals that the majority of the focus has been on the prevalence, predictive factors and residual associations of exposure to violence among Native American women. Although men living in these areas have received less attention, it is important to be familiar with the available research related to the victimization of men. Gaining a broader understanding of how all individuals living on tribal lands experience violence will assist in the ability to be sensitive to issues faced by both men and women and aid counselors to choose culturally competent interventions.


Prevalence of Violence Against Native American Men

Robin, Chester, Rasmussen, Jaranson, and Goldman (1997) reported that among Native American men residing in Southwest tribal communities, 81% reported exposure to a violent act at some point in their lives. Among Native American men living on seven tribal communities in Montana, nearly one in ten reported exposure to physical violence in the year preceding the survey (Harwell, Moore, & Spence, 2003). This figure was nearly double the prevalence reported by women living in the same communities, although women reported higher frequencies of sexual violence and emotional abuse (Harwell et al., 2003). A study on the prevalence of aggravated assault among Native Americans living on tribal lands found that men were victims of severe physical violence at a rate of 36% since turning 18 years of age (Yuan et al., 2006). These reports suggested that although women may be exposed to various types of violence at higher rates in tribal communities, men may be subject to a higher likelihood of physical injury due to exposure to higher rates of physical violence.


Native American men are more likely than men of any other ethnicity to experience traumatic brain injury (TBI) as a result of violence (Nelson, Rhoades, Noonan, & Manson, 2007). Moreover, Native American men living in rural tribal communities are more likely to seek medical attention for a TBI than those living in urban areas (Nelson et al., 2007). Hence, a Native American man living on tribal lands appears to have a higher risk than any other population in the United States to experience severe enough violence to sustain an injury to the brain. The only comparable population was concluded to be African-American men living in urban inner-city communities (Nelson et al., 2007).


Although domestic violence is typically considered by many to be a women’s issue, Robin, Chester, and Rasmussen (1998) surveyed both men and women living on tribal lands about their lifetime and recent prevalence of intimate partner violence experiences. These researchers concluded that men reported rates of lifetime prevalence of domestic violence at 91%, with 31% reporting recent exposure to violence perpetrated by intimate partners. However, despite these high rates, men were concluded to be less likely to need medical assistance as a result of domestic violence when compared to the women in their tribal communities.


Predictive Associations of Violence Against Native American Men

     Homicide occurrence among Native American men living on tribal lands has been reported to be highly correlated to unemployment and impoverished standards of living (Lester, 1995). Criminal mentalities that often accompany a lack of occupational routine and structure may contribute to increases in the capacity to commit homicide (Lester, 1995). It is possible that factors that lead to unemployment, such as substance use, play a role in the propensity to experience or commit homicide in tribal communities (Koss et al., 2003).


Yuan et al. (2006) investigated the predictive characteristics of physical violence exposure among Native American men living in six distinct tribal communities, studying the effects of variations in demographics, alcohol dependence in adulthood, cultural variables, regional variables, and adverse childhood experiences on the prevalence for physical violence victimization. The researchers concluded that only adverse childhood experiences and alcohol dependence in adulthood mediated the likelihood of exposure to violence across similar communities.


Native American men under the age of 18 have been studied by researchers to determine predictive characteristics and protective factors related to the perpetration and exposure to physical violence. Pu et al. (2013) concluded that men under the age of 18 living on tribal lands have more desire to learn and practice traditional Native American culture than the women in their similar age ranges. The men who reported high levels of desire to practice their traditional culture also displayed higher levels of self-efficacy to avoid perpetration and victimization of physical violence. High levels of parental involvement were associated with lower levels of exposure to violence among this population.


Residual Associations for Violence Against Native American Men

     While the prevalence and predictive characteristics of exposure to violence among Native American men living on tribal lands have been understudied, there have been higher rates of contributions from empirical literature regarding the residual associations related to victimization. When surveyed using qualitative methods, Native American men reported that one substantial observed consequence of violence on tribal lands is the expanding discrepancies between traditional Native American values and behaviors witnessed in tribal communities (Matamonasa-Bennett, 2013). These men reported beliefs that Native American men did not frequently commit violence against Native American men or women until the introduction of colonization and alcohol. These men feared that continued trends in violence would serve to further the gap between the values held by traditional Native American culture and the values of those living on tribal lands.


Beals et al. (2013) studied PTSD among 1,446 Native Americans living in southwest tribal communities and 1,638 Native Americans living in Northern Plains tribal communities. Rates of traumatic stress symptomology that suggested PTSD were reported to vary between 5.9% and 28.3% for Native American men. On average, men reported rates of PTSD at 14.8%, which is approximately triple the national average for men (Ford et al., 2015). Therefore, although Native American women living on tribal lands have reported higher rates of PTSD than men, the discrepancy between the rates on tribal lands and the national average is far more pronounced for Native American men than it is for women. Beals et al. also concluded that Native American men were just as likely to develop traumatic stress symptoms (15.9%) as men in other populations following exposure to traumatic stressors. This indicates that the increased frequency of PTSD among Native American men living on tribal lands is a function of increased exposure to traumatic experiences. There also may be certain types of violence that lead to increased likelihood for the development of PTSD. Researchers have reported that sexual violence exposure has been associated with increased anxiety symptoms among Native American men (Gnanadesikan, Novins, & Beals, 2005). Furthermore, Native American men who have experienced six or more incidents of violence are significantly more likely to develop traumatic stress symptoms. Indeed, PTSD is a prevalent and serious residual effect of exposure to violence in tribal communities.


Cardiovascular disease (CVD) has been concluded to be higher among Native American men living on tribal lands when compared to men in other populations (Sawchuk et al., 2005). When researchers have examined factors that correlate to CVD, only exposure to violent traumatic stressors and subsequent traumatic stress symptoms have been significantly correlated to increased likelihood for CVD. General stress and the presence of depression do not account for the same variance on CVD as traumatic stress (Sawchuk et al., 2005). It is possible that exposure to violence among Native American men can lead to decreased life expectancy due to serious heart conditions.


Similar to the reports of residual associations for Native American women who experience violence, Native American men living on tribal lands with a history of victimization report increased prevalence of high-risk behaviors, including substance abuse (M. C. Jones, Dauphinais, Sack, & Somervell, 1997). Because high-risk behaviors can be considered both predictive characteristics and residual effects of exposure to violence, these behaviors can seemingly serve to initiate and exacerbate violence. For example, if a Native American man abuses alcohol, effectively lowering inhibitions, he may find himself at increased risk to be subjected to a physical altercation. As a result, the man may turn to alcohol as a means to cope with reactions to the exposure to violence, creating a cycle of substance abuse that heightens the likelihood of future exposure to violence, culminating in the need for mental health care.


Barriers to Mental Health Care


Native American victims of violence are more likely than other populations to require medical care due to the severity of the sustained injuries (Bachman, Zaykowski, Lanier, Poteyeva, & Kallmyer, 2010). Because the development of PTSD is more frequent when physical trauma occurs as a result of violence (Ford et al. 2015), it is possible that Native Americans living on tribal lands are a population with an increased need for effective mental health interventions. The Indian Health Service (IHS) is the primary medical and mental health agency providing care to Native Americans on tribal lands (Katz, 2004). The IHS system has chronically reported issues with underfunding and understaffing due, in part, to legislative policies that do not allow for funds to be provided to IHS through the United States government. As a result, the care that individuals receive through the agency is often lacking in comparison to the standards of non-tribal health care agencies. Furthermore, these services are not guaranteed to those with Native American heritage, and nearly half of the low-income Native American individuals on tribal lands cannot afford health insurance (Katz, 2004). Effectively, this renders the population within tribal lands as having the highest risk for exposure to violence, yet with limited resources to treat the effects of violence.


The largest barrier to receiving mental health care in the wake of a sexual violence crisis for Native Americans living on tribal lands may be the lack of available services within a reasonable distance. Juraska, Wood, Giroux, and Wood (2014) examined 873 Sexual Assault Response Teams (SARTs) within a designated proximity to Native American lands. SARTs are teams that provide emergency mental health care and advocacy to survivors of sexual assault and are widely used in the United States on both tribal and non-tribal lands. They reported that only 30.7% of these lands fell within a 60-minute driving range from a SART or sexual assault examiner. These researchers also reported that more than two-thirds of the tribal lands in the continental United States would not be accessible to SARTs and 381 of the 605 tribal communities were left with no coverage. Considering the high level of sexual violence that has been reported on tribal lands, it appears that SARTs are not being deployed in the areas that may need mental health care and advocacy the most.


In the area of domestic violence, researchers have concluded that significant stigmas have led to underreporting of violence by women to IHS staff (Clark, 2001). Specifically, Native American women have shared with researchers that they refused to report incidents of domestic violence to IHS staff because of the manner in which the topic was addressed and fear regarding how the staff may react. Moreover, although screening for domestic violence has become commonplace among medical facilities in the United States, only 62% of the surveyed IHS facilities had protocols to screen for domestic violence (Clark, 2001). If survivors of violence do not feel safe reporting violence to their medical and mental health professionals, appropriate aid cannot be deployed to prevent the development (or exacerbation) of traumatic stress symptoms. Furthermore, it has been theorized that Native American men and women underreport violence to IHS staff because of altered perceptions as to what constitutes violence (Tehee & Esqueda, 2008). In particular, incidents that may be reported as abuse by other populations may not be severe enough to be considered reportable violence by Native American individuals living on tribal lands.


Furthermore, a general lack of multicultural competency displayed by counselors toward Native Americans appears to be a significant barrier for this population receiving adequate mental health care. Although there has been a push for increased multicultural competency in the field of counseling in the last decade (Toporek & Vaughn, 2010), educational institutions have not traditionally focused on providing counselors-in-training the capacities for effectively working with diverse cultures (Garrett & Herring, 2001; Ponterotto, Casas, Suzuki, & Alexander, 2009; Sue, Arredondo, & McDavis, 1992). Even the theories that have enjoyed the most empirical support, such as cognitive behavioral therapy, have been scrutinized for a general lack of applicability to diverse cultures (Graham, Sorenson, & Hayes-Skelton, 2013). In fact, many common therapeutic approaches may serve to further marginalize minority populations by expecting clients to conceptualize issues and develop problem-solving strategies from the dominant culture perspective (Sue & Sue, 2012).


     Even when research and educational entities commit to better competency in understanding and working with minority populations, the majority of the attention is allotted to Hispanic, Black, and Asian populations. It is theorized that these phenomena may contribute to low rates of mental health seeking behaviors and high rates of dropout from Native American clients (Garrett & Herring, 2001). Moreover, it has been theorized that counselors, due to multicultural competency deficiencies, may even reinforce continued physical and sexual violence in Native American populations by focusing only on a client’s behavioral flaws as a means of therapeutic intervention (E. Duran, Duran, Heart, & Horse-Davis, 1998). Clearly, increased efforts in training counselors to work with Native American clients are necessary to adequately provide mental health services to this high-need population.


Implications for Counselors


To summarize, Native Americans living on tribal lands are at a higher risk for exposure to violence than other populations (Wahab & Olson, 2004). Predictive characteristics associated with increased risk include low socioeconomic status (Malcoe et al., 2002), unemployment (Lester, 1995), gender (Oetzel & Duran, 2004), cultural affiliation (Yuan et al., 2006), substance abuse (Ferraro, 2008), relationship status (Roodman & Clum, 2001), history of previous exposure to violence (Bryant-Davis et al., 2009), and adverse childhood experiences (Yuan et al., 2006). Residual associations to experiencing violence on tribal lands include PTSD (Beals et al., 2013; B. Duran et al., 2009), symptoms of anxiety and depression (Bryant-Davis et al., 2009), chronic pain (Buchwald et al., 2005), substance abuse (Yuan et al., 2006), increased high-risk behaviors such as promiscuity (Hobfoll et al., 2002), suicidal ideation (Bohn, 2003), decreased communal cohesion (Matamonasa-Bennett, 2013), and cardiovascular disease (Sawchuk et al., 2005).


Barriers experienced by Native Americans living on tribal lands for obtaining mental health services have been identified as poor standards in IHS agencies (Katz, 2004), inability to access mental health crisis SARTs (Juraska et al., 2014), underreporting of violence by Native American clients (Clark, 2001), and a lack of multicultural competency displayed by counselors (Garrett & Herring, 2001). In understanding barriers faced by Native Americans living on tribal lands, counselors can make informed decisions about intervention strategies that best aid clients in overcoming these barriers. This may mean altering therapeutic intervention approaches, increasing focus on establishing positive working alliances with clients through increased cultural competency, meeting with clients in their local communities, and advocating for systemic change in governmental and mental health agencies. Working to help eliminate the barriers to obtaining mental health services among Native Americans living on tribal lands may be the difference between those who fall into the cycle of re-victimization and those who break this cycle through collaborative efforts with the counselor.


Despite the disheartening research revealing the prevalence of violence among Native Americans living on tribal lands, this phenomenon does not appear to be common knowledge or an area of passion among some mental health counselors. Without a shift in the ways counselors view and treat violence within this population, oppression which lends to violence exposure and consequent mental health issues is not likely to subside as a result of mental health intervention. In particular, mental health counselors must commit to gaining increased competency in working with Native Americans and advocate for effective and ethical therapeutic strategies.


Counseling Practice Implications

Although many clinical approaches have been reported to exhibit limited effectiveness when working with Native American populations, some researchers have attempted to expand on empirically validated approaches in order to increase the likelihood of effectiveness with this population. Bigfoot and Schmidt (2010) adapted cognitive behavioral therapy (CBT) approaches to incorporate teachings from the traditional Native American Medicine Wheel. These researchers concluded that their method of therapy was particularly beneficial for Native American children with traumatic stress symptoms. When working with Native American survivors of trauma, counselors can expand this model by incorporating the Native American Medicine Wheel throughout the cognitive restructuring process.


The Native American Medicine Wheel is comprised of four sections with various concepts dedicated to each section. The wheel symbolizes how various elements in one’s life are separate, yet interconnected. When utilizing the wheel as an intervention tool, counselors can focus on the sections dedicated to thoughts, emotions, behavior and spirituality. CBT aims to help clients identify, challenge and change dysfunctional thought patterns in order to alter emotions and behaviors. Therefore, the counselor can use the Native American Medicine Wheel as a guide to help the client conceptualize how change is created. It may be beneficial to begin by focusing on the section dedicated to spirituality in order to gain insight into the spiritual beliefs and values held by the client. The knowledge gained in this process will help the counselor to understand what spiritual practices may be incorporated into sessions. The counselor can proceed by focusing on the sections dedicated to cognition, emotion and behavior. The suggested goals for counseling sessions are provided in Figure 1.

















Figure 1. Incorporating the Native American Medicine Wheel into CBT.



As the counselor and client move through these sections, the counselor also can incorporate the other elements within each section. For example, while processing the section dedicated to emotion, the counselor can incorporate visual imagery of summer and water while practicing relaxation techniques. The counselor and client can process how the role of the teacher applies to training oneself to cope with environmental triggers. It is further suggested that the counselor find opportunities to use traditional Native American healing methods during counseling sessions such as (a) smudging, (b) using Native American symbols to represent new topics, (c) incorporating Native American languages, (d) creating visual representations using Native American art forms, (e) forming talking circles, and (f) consulting with elders in the tribal communities (Bucharski, Reutter, & Ogilvie, 2006). Counselors also should be educated on the theory of historical trauma to assist clients in understanding how the traumas of the past impact the Native American community today. Native American clients should be educated regarding how previous traumas can impact current behavior across generations (Brown-Rice, 2013).


Although several researchers have called for increased focus on spiritual exercises while working with Native American clients (Bucharski et al., 2006; Matheson, 1996), counselors must be cautious when implementing these interventions. Matheson (1996) urged non-Native American counselors to consider the difference between cultural competencies and understanding. He reported that non-Native counselors often attempt to implement a Native American spiritual exercise as the counselor understands it, which can prove to be misguided, counterproductive and offensive. Instead, it is best to collaborate with Native American clients about how an activity should be executed and seek permission to engage in the exercise with the client. This will help to account for any violations of sacred practices and saturate the power between the counselor and client. Matheson theorized that Native Americans are often turned away from counseling due to perceived power differential and lack of interdependence between the counselor and client.


There also may be environmental changes that can be incorporated into counseling that help facilitate spiritual expression when working with Native American clients. For example, counselors may decide to hold counseling sessions outside of an office setting. A counselor may take the client to a garden or observe nature while conducting counseling sessions. Moreover, a counselor may use pet therapy techniques to help Native American clients feel a connection to nature. This technique also may help clients to express empathy (Hunter & Sawyer, 2006). Again, it is best if the counselor collaborates with the client to ensure that the setting changes are congruent with the personal beliefs and values of the client.


When a high level of exposure to traumatic stressors is present, as it often is with Native American populations, a client is likely to have biological and environmental needs that supersede mental health counseling. Targeting these needs early in the counseling relationship is likely to increase the ability of the client to meet counseling objectives. B. Jones, Tilden, and Gaines-Stoner (2008) suggested a multi-modal approach to working with Native Americans living on tribal lands due to the nature of complex trauma. First, Jones suggested that counselors build the therapeutic alliance with Native American clients by demonstrating a high level of value for sharing, autonomy and informal interpersonal interaction. Second, Jones suggested that counselors be active in consulting with agencies to provide aid with substance abuse services, housing, legal assistance, transportation, childcare and job development.


Of course, a multi-modal approach would be particularly difficult to implement for Native Americans who present with substantial barriers to mental health care. Although it is crucial that the counseling field advocate for bureaucratic changes, creating a trusting and therapeutic rapport with Native American clients is the barrier that counselors must address immediately. Native Americans living on tribal lands prefer counselors who are sensitive to Native American values and use a non-directive theoretical approach to counseling (Bichsel & Mallinckrodt, 2001). This suggests that counselors who employ more directive approaches, such as the cognitive behavioral techniques previously described, may incorporate increased person-centered approaches while building the initial working alliance with Native American clients. Native Americans have reported a preference for frequent use of collaboration (Scholl, 2006) and little use of concrete advice-giving in counseling (Garrett, 2003).


Counselors can give special considerations to Native American clients when they have been exposed to sexual violence. In particular, counselors can aid these individuals in the process of identifying and challenging self-blame and shame; survivors of sexual assault report feelings of shame and self-blame at a rate of 75% (Vidal & Petrak, 2007). Perspectives of survivors have been linked to negative self-concept (Miller, Handley, Markman, & Miller, 2010) and PTSD (Ullman, Townsend, Filipas, & Starzynski, 2007). It is important to note that the relationship between self-blame and PTSD has been theorized to be mediated by negative social reactions (Ullman et al., 2007). This suggests that processing blame and taking a position of unconditional positive regard toward the client can function to decrease PTSD symptoms.


High levels of self-blame among survivors of physical and sexual violence can serve as a predictor for re-victimization. Miller, Markman, and Handley (2007) reported increased re-victimization rates among survivors of sexual assault who reported elevated levels of self-blame. These conclusions were echoed by Edwards, Kearns, Gidycz, and Calhoun (2012), who determined that women who reported high levels of self-blame were more likely to remain in an intimate relationship with perpetrators of domestic abuse. Although there is no research available regarding the role self-blame plays among Native Americans living on tribal lands, it is clear that counselors must assess for self-blame when working with this population. In order to accomplish this task, and to collect needed research data, counselors can administer the Sexual Assault Symptom Scale (SASS), which includes subscales for self-blame, disclosure shame, safety fears and depression (Ruch, Gartrell, Amedeo, & Coyne, 1991).


Directions for Future Research


In order to increase the effectiveness of counseling interventions with Native American clients, there are several areas that warrant investigation. First, researchers should gain a better understanding of the differences between Native American tribes. The rate of violence exposure between tribes varies greatly (Oetzel & Duran, 2004), with some tribal communities being less impacted. Thus, researchers should conduct a more thorough examination of the prevalence, predictive characteristics and residual associations related to exposure to violence in tribal communities to determine the practices of those with lower levels of violence. In better understanding these factors, researchers can focus their attention on specified preventative approaches utilized by these communities and guide future counseling practices.


Furthermore, researchers should devote increased efforts to collecting data on male Native American survivors of violence. Certainly, researchers have investigated assault and homicide among this population, but prevalence and residual factors related to domestic and sexual violence is lacking in the literature. Many male survivors of physical and sexual assault are hesitant to report their experiences due to social factors including (a) fear of judgment by peers, (b) fear they will not be believed, (c) fear of being labeled homosexual, and (d) concerns about counselors maintaining confidentiality (Sable, Danis, Mauzy, & Gallagher, 2006). However, it is not known what additional factors may contribute to the hesitation of Native American men to report violence. Increased knowledge in this area could have significant implications for the prevention of violence on tribal lands among men, as well as positively impact the counseling process.


The negative impact that self-blame has on survivors of trauma has been well established (Miller et al., 2010; Ullman et al., 2007). However, the impact of self-blame in the Native American community, the population most affected by exposure to violence, has not been researched. It is important for counselors to know whether the existing research on self-blame is applicable to the Native American community in order to understand whether techniques must be altered. If self-blame was determined to be more or less prevalent among this population, researchers can help instruct counselors how to alter interventions to better account for cultural factors.


Researchers should aim to better understand the barriers to Native Americans living on tribal lands in obtaining mental health services. Specifically, the interpersonal factors in seeking services, the capacity of individuals to find services, and the role of bureaucracy in limiting resources should be further investigated. Gaining a greater understanding of efficient methods of deploying mental health services to Native American populations is only beneficial if administering services is a realistic possibility. Given that Native American people have a history of being diminished and marginalized in the interest of research (Walters & Simoni, 2009), research efforts need to be conducted in a culturally appropriate and ethical manner (Brown-Rice, 2013). If the mental health community were to commit to these research endeavors, it would provide a sufficient foundation for creating changes in the effectiveness of the treatment of this highly victimized population.


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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Adam Hardy, NCC, is a Counselor at Glory House in Sioux Falls, SD. Kathleen Brown-Rice, NCC, is an Assistant Professor at the University of South Dakota. Correspondence can be addressed to Adam Hardy, 3005 West Courtyard Lane, Sioux Falls, SD 57108,


Burnout, Stress and Direct Student Services Among School Counselors

Patrick R. Mullen, Daniel Gutierrez

The burnout and stress experienced by school counselors is likely to have a negative influence on the services they provide to students, but there is little research exploring the relationship among these variables. Therefore, we report findings from our study that examined the relationship between practicing school counselors’ (N = 926) reported levels of burnout, perceived stress and their facilitation of direct student services. The findings indicated that school counselor participants’ burnout had a negative contribution to the direct student services they facilitated. In addition, school counselors’ perceived stress demonstrated a statistically significant correlation with burnout but did not contribute to their facilitation of direct student services. We believe these findings bring attention to school counselors’ need to assess and manage their stress and burnout that if left unchecked may lead to fewer services for students. We recommend that future research further explore the relationship between stress, burnout and programmatic service delivery to support and expand upon the findings in this investigation.


Keywords: burnout, stress, school counselors, student services, service delivery


The American School Counselor Association (ASCA; 2012) recommends that school counselors enhance the personal, social, academic and career development of all students through the organization and facilitation of comprehensive programmatic counseling services. Delivery of student services is part of a larger framework articulated by ASCA’s National Model (2012) that also includes management, accountability and foundation components of school counseling programs. However, ASCA notes that school counselors should “spend 80 percent or more of their time in direct and indirect services to students” (ASCA, 2012, p. xii). ASCA defines indirect student services as services that are in support of students and involve interactions (e.g., referrals, consultations, collaborations and leadership) with stakeholders other than the student (e.g., parents, teachers and community members). On the other hand, direct student services are interactions that occur face-to-face and involve the facilitation of curriculum (e.g., classroom guidance lessons), individual student planning and responsive services (e.g., individual, group and crisis counseling). In either case, ASCA charges school counselors with prioritizing the delivery of student services.


As a part of their work, school counselors often incur high levels of stress that may result from multiple job responsibilities, role ambiguity, high caseloads, limited resources for coping and limited clinical supervision (DeMato & Curcio, 2004; Lambie, 2007; McCarthy, Kerne, Calfa, Lambert, & Guzmán, 2010). In addition, burnout can result from the ongoing experience of stress (Cordes & Dougherty, 1993; Maslach, 2003; Schaufeli & Enzmann, 1998) and can result in diminished or lower quality rendered services (Lawson & Venart, 2005; Maslach, 2003). While research on burnout is common in the school counseling literature (Butler & Constantine, 2005; Lambie, 2007; Wachter, Clemens, & Lewis, 2008; Wilkerson & Bellini, 2006), studies have not focused on the relationship between burnout and school counselors’ service delivery. Yet, burnout has the potential to produce negative consequences for the work rendered by school counselors and could result in fewer services for students (Lambie, 2007; Lawson & Venart, 2005; Maslach, 2003). Therefore, the purpose of this research was to examine the contribution of school counselors’ levels of burnout and stress to their delivery of direct student services.


School Counselors and the Delivery of Student Services


Research on school counselors’ delivery of student services has produced positive findings. In a meta-analysis that included 117 experimental studies, Whiston, Tai, Rahardja, and Eder (2011) identified that, in general, school counseling services have a positive influence on students’ problem-solving and school behavior. Furthermore, in schools where school counselors completed higher levels of student services focused on improving academic success, personal and social development, and career and college readiness, students experienced a variety of positive outcomes, such as increased sense of belongingness, increased attendance, fewer hassles with other students, and less bullying (Dimmitt & Wilkerson, 2012). Moreover, researchers have shown that the higher occurrence of school counselor-facilitated services is beneficial for students’ educational experience and academic outcomes (Carey & Dimmitt, 2012; Lapan, Gysbers, & Petroski, 2001; Wilkerson, Pérusse, & Hughes, 2013). Overall, the services conducted by school counselors have a positive impact on student success. As such, research investigating the factors related to higher incidence of school counselors’ direct student services could provide significant educational benefits to schools.


Researchers have examined a variety of topics that relate to increased student services. Clemens, Milsom, and Cashwell (2009) found that if school counselors had a good relationship with their principal and were engaged in higher levels of advocacy, they were likely to have increased implementation of programmatic counseling services. Another study concluded that school counselors’ values were not associated with the occurrence of service delivery, but researchers did find counselors with higher levels of leadership practices also delivered more school counseling services (Shillingford & Lambie, 2010). Other factors related to increased levels of school counselors’ service delivery are increased job satisfaction (Baggerly & Osborn, 2006; Pyne, 2011) and higher self-efficacy (Ernst, 2012; Mullen & Lambie, 2016). These studies provided notable contributions to the literature; however, at this time no known studies have examined the relationship among school counselors’ burnout, perceived stress and direct student services.


Stress and Burnout Among School Counselors


Stress is a significant issue that relates to the impairment of work performance (Salas, Driskell, & Hughes, 1996) and is a likely problem for school counselors. The construct of stress has a rich history in scientific literature dating back to the 1930s (Cannon, 1935; Selye, 1936). Selye (1980) articulated one of the first broad definitions of stress by defining it as the “nonspecific results of any demand upon the body” (p. vii). Over time, various authors developed an assortment of definitions (Ivancevich & Matteson, 1980; Janis & Mann, 1977; McGrath, 1976), but Lazarus and Folkman’s (1984) definition of stress is common among scholars (Driskell & Salas, 1996; Lazarus, 2006). In their Transactional Model of Stress and Coping, Lazarus and Folkman (1984) defined stress as a “particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her wellbeing” (p. 19). Lazarus and Folkman conceptualized that stress results from an imbalance between one’s perception of demands or threats and their ability to cope with the perceived demands or threats. Consequently, one’s appraisal of demands and their assessment of their coping ability becomes a critical issue in relationship to whether or not the demand will trigger a stress response.


McCarthy et al. (2010) applied Lazarus and Folkman’s model of stress (1984) to school counselors using an instrument that measures the demands and resources experienced by school counselors called the Classroom Appraisal of Resources and Demands–School Counselor Version (McCarthy & Lambert, 2008). McCarthy et al. (2010) found that school counselors who reported challenging demands as a part of their job also had higher levels of stress. This finding is troubling considering that school counselors oftentimes encounter ambiguous job duties, inconsistent job roles and conflicts in their job expectations (Burnham & Jackson, 2000; Culbreth, Scarborough, Banks-Johnson, & Solomon, 2005; Lambie, 2007; Scarborough & Culbreth, 2008). An additional concern is that stress occurring over an extended period of time can lead to emotional and physical health problems (Sapolsky, 2004) along with increased likelihood of leaving the profession (DeMato & Curcio, 2004). Fortunately, prior research reveals that school counselors have reported low stress levels (McCarthy et al., 2010; Rayle, 2006). Still, research on school counselors’ stress and its effects on the services they provide is important.


An additional factor that we believe may have an impact on direct student services is burnout. Burnout was first recognized in the 1970s (Freudenberger, 1974; Maslach, 1976) and is considered to have significant consequences for counseling professionals (Butler & Constantine, 2005; Lambie, 2007; Lawson, 2007; Lee et al., 2007). The topic of burnout is common in the literature across many disciplines (Schaufeli, Leiter, & Maslach, 2009) and has been given particular attention in school counseling research (Butler & Constantine, 2005; Lambie, 2007; Wachter et al., 2008; Wilkerson & Bellini, 2006). Freudenberger (1974, 1986) suggested that burnout results from depleted energy and the feelings of being overwhelmed that emerge from the exposure to diverse issues related to helping others, which over time affects one’s attitude, perception and judgment. Pines and Maslach (1978) described burnout as an ailment “of physical and emotional exhaustion, involving the development of negative self-concept, negative job attitude, and loss of concern and feelings for clients” (p. 234). In 1981, the Maslach Burnout Inventory (MBI) was developed as a method to measure one’s experience of burnout in the helping and human service field (Maslach & Jackson, 1981).


More recently, Lee et al. (2007) expanded the measurement of burnout and presented the construct of counselor burnout, which they defined as “the failure to perform clinical tasks appropriately because of personal discouragement, apathy to symptom stress, and emotional/physical harm” (p. 143). Within their model, Lee and associates found that counselor burnout includes the constructs of exhaustion, negative work environment, devaluing clients, incompetence and deterioration in personal life. These constructs correlate with the factors measured by the MBI (Maslach & Jackson, 1981), but provide a definition consistent with the work of school counselors (Gnilka, Karpinski, & Smith, 2015).


Many researchers have explored factors related to school counselor burnout. Overall, scholars have found that school counselors report low levels of burnout (Butler & Constantine, 2005; Gnilka et al., 2015; Lambie, 2007; Wachter et al., 2008; Wilkerson & Bellini, 2006). Nonetheless, researchers also reported that higher collective self-esteem is associated with a higher sense of personal accomplishment and lower emotional exhaustion (Butler & Constantine, 2005), whereas higher levels of ego development are associated with higher personal accomplishment (Lambie, 2007). Moreover, Wilkerson and Bellini (2006) discovered that school counselors who handle stressors with emotion-focused coping are at a higher risk of experiencing burnout symptoms, and Wilkerson (2009) established that school counselors’ emotion-focused coping increases their likelihood of experiencing symptoms of burnout. Yet, there is no research on the connection between school counselors’ burnout and the direct student services they provide despite a high likelihood that burnout is the cause of fewer and deteriorated services for students (Maslach, 2003).


The purpose of this study was to build upon existing literature regarding school counselors’ stress, burnout and their facilitation of direct student services. The guiding research questions were: (a) Do practicing school counselors’ levels of burnout and perceived stress contribute to their levels of service delivery? and (b) Do practicing school counselors’ levels of stress correlate with their burnout? Consequently, the following research hypotheses were examined: (a) School counselors’ degree of burnout and perceived stress contributes to their facilitation of direct student services, and (b) School counselors’ degree of perceived stress correlates positively with their level of burnout.





To answer the research questions associated with this study, we employed a cross-sectional research design (Gall, Gall, & Borg, 2007). Furthermore, this study utilized online survey data collection procedures. Prior to any data collection, we received approval from the Institutional Review Board at the first author’s university. During the first step in the data collection process, we retrieved the name and e-mail address of every school counselor listed in the ASCA online directory of membership. Next, we generated a simple random sample of school counselors. Then, we sent the sample selected from the ASCA online directory a series of three e-mails that aligned with tailored design method (Dillman, Smyth, & Christian, 2009) recommendations for survey research. Each e-mail contained a brief description of the survey and a link to the online survey managed by Qualtrics (2013). If a participant wished to take the survey, he or she was directed to the Web site that posted the explanation of the study. If they agreed to participate, they would move forward and complete the survey. Participants were screened as to whether they were practicing school counselors or not (e.g., student, counselor educator or retired). Of the 6,500 participants sampled, 41 indicated they were not a practicing school counselor. In addition, 312 e-mails were not working at the time of the survey. Out of the 6,147 practicing school counselors surveyed, 1,304 (21.21% visit response rate) visited the survey Web site and 926 completed the survey in its entirety, which resulted in a 15.06% useable response rate. The response rate received for this study is high in comparison to studies using similar methods (e.g., 14%, Harris, 2013; 11.4%, Mullen, Lambie & Conley, 2014).


Participant Characteristics

     Participants (N = 926) were practicing school counselors in private, public and charter K–12 educational settings from across the United States. The mean age was 43.27 (SD = 10.03) and included 816 (88.1%) female and 110 (11.9%) male respondents. The participants’ ethnicity included 50 (5.4%) African Americans, 5 (.5%) Asian Americans, 29 (3.1%) Hispanic Americans, 11 (1.2%) Multiracial, 2 (.2%) Native Americans, 4 (.4%) Pacific Islanders, 811 (87.6%) European Americans, and 13 (1.5%) participants who identified their ethnicity as “Other.” On average, participants had 10.97 (SD = 6.92) years of experience and 401.45 (SD = 262.05) students on their caseload. The geographical location of the participants’ work setting favored suburban (n = 434, 46.9%) and rural communities (n = 321, 34.7%) with fewer school counselors working in urban settings (n = 171, 18.5%). Most participants reported that they worked in the high school grade levels (n = 317, 34.2%) closely followed by elementary (n = 270, 29.2%) and middle school or junior high school (n = 203, 21.9%) grade levels, with 136 (14.7%) respondents working in another grade level format (e.g., grades K–12, K–8, or 6–12).



This study used the (a) Counselor Burnout Inventory (CBI; Lee et al., 2007), (b) the School Counselor Activity Rating Scale (SCARS; Scarborough, 2005), and (c) the Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983). Participants also completed a researcher-created demographics form regarding their personal characteristics (e.g., age, gender and ethnicity) and work-related characteristics (e.g., location type, grade level, caseload, experience as a school counselor and percentage of time they directly work with students).


CBI. The CBI (Lee et al., 2007) is a 20-item self-report measure that examines counselor burnout across five domains. The domains that make up the CBI include: (a) exhaustion, (b) incompetence, (c) negative work environment, (d) devaluing client, and (e) deterioration in personal life. The CBI makes use of a 5-point Likert rating scale that ranges from 1 (never true) to 5 (always true) and examines emotional states and behaviors representative of burnout. Some sample items include “I feel exhausted due to my work as a counselor” (exhaustion), “I feel I am an incompetent counselor” (incompetence), “I feel negative energy from my supervisor” (negative work environment), “I have little empathy for my clients” (devaluing client), and “I feel I have poor boundaries between work and my personal life” (deterioration in personal life). Lee et al. (2007) demonstrated the construct validity of the CBI through an exploratory factor analysis that identified a five-factor solution in addition to a confirmatory factor analysis that supported the five-factor model with an adequate fit to the data.


Gnilka et al. (2015) found support for the five-factor structure of the CBI (Lee et al., 2007) with school counseling using confirmatory factor analysis, which supports the CBI as an appropriate measure for school counselor burnout. Lee et al. (2007) established convergent validity for the CBI based upon the correlations between the subscales on the Maslach Burnout Inventory-Human Services Survey (Maslach & Jackson, 198l) and the CBI. In prior research, the Cronbach’s alphas of the CBI subscales indicated good internal consistency (Streiner, 2003) with score ranges of .80 to .86 for exhaustion, .73 to .81 for incompetence, .83 to .85 for negative work environment, .61 to .83 for devaluing client, and .67 to .84 for deterioration in personal life (Lee et al., 2007; Lee, Cho, Kissinger, & Ogle, 2010; Puig et al., 2012). The internal consistency coefficients of the CBI in this investigation also were good (Streiner, 2003) with Cronbach’s alphas of .87 for exhaustion, .79 for incompetence, .84 for negative work environment, .79 for devaluing client, and .81 for deterioration in personal life.


SCARS. The SCARS (Scarborough, 2005) is a 48-item verbal frequency measure that examines the occurrence that school counselors actually perform and prefer to perform components of the ASCA National Model (2012). The SCARS measures school counselors’ ratings of activities based on the four levels of interventions articulated by ASCA (1999) and the ASCA National Model (2003). Unfortunately, a more recent version of the SCARS that articulates the new ASCA National Model (2012) does not exist. Nevertheless, this study utilized two SCARS scales (counseling and curriculum) that measure the incidence of direct student services. To the benefit of this investigation, the direct services measured on the SCARS have not changed in the new edition of the ASCA National Model (2003, 2012). Similar to Shillingford and Lambie (2010) and Mullen and Lambie (2016), this investigation utilized the actual scale, but not the prefer scale, on the SCARS (Scarborough, 2005) because this study sought to examine the frequency that school counselors delivered direct student services, not their preferences and not the difference between their preference and actuality. The subscales that measure direct student services used in this study included the counseling (e.g., group and individual counseling interventions; 10 items) and curriculum (e.g., classroom guidance interventions; 8 items) subscales, whereas the coordination, consultation and other activities scales were not used because they measure indirect activities.


The SCARS (Scarborough, 2005) assesses the frequency of school counselor service delivery with a 5-point Likert rating scale that ranges from 1 (I never do this) to 5 (I routinely do this). Scores on the SCARS can be total scores or mean scores. Some sample items from the counseling subscale are “Counsel with students regarding school behavior” and “Provide small group counseling for academic issues.” Some sample items from the curriculum subscale are “Conduct classroom lessons addressing career development and the world of work” and “Conduct classroom lessons on conflict resolution.” Scarborough (2005) examined the validity by investigating the variances in score on the actual scale based on participant grade level and found that participants’ grade level had a statistically significant effect across the scales with small to large effect sizes (e.g., ranging from .11 to .68[ω2]), which supported the convergent validity of the SCARS. Additionally, construct validity was supported using factor analysis. In prior research using the SCARS, the internal consistency of the counseling and curriculum scales was strong with Cronbach’s alphas of .93 for the curriculum actual scale and .85 for the counseling actual scale (Scarborough, 2005). The internal consistency coefficients of the SCARS actual subscales in this investigation were good (Streiner, 2003) with Cronbach’s alphas of .77 for the counseling scale and .93 for the curriculum scale.


PSS. The PSS (Cohen et al., 1983) is a 10-item self-report measure that examines the participants’ appraisal of stress by asking about feelings and thoughts during the past month. The PSS uses a 5-point Likert scale that ranges from 0 (never) to 4 (very often) and includes four positively stated items that are reverse coded. Some sample items include, “In the last month, how often have you felt that you were on top of things?” (reverse coded), and “In the last month, how often have you been upset because of something that happened unexpectedly?” The PSS has been shown to have acceptable internal consistency with Cronbach’s alphas ranging from .84 to .91 (Chao, 2011; Cohen et al., 1983; Daire, Dominguez, Carlson, & Case-Pease, 2014). The internal consistency coefficient of the PSS in this study also was acceptable (Streiner, 2003) with a Cronbach’s alpha of .88.




Preliminary Analysis

Initial screening of the data included the search for outliers (e.g., data points three or more standard deviations from the mean) using converted z-scores (Osborne, 2012), which resulted in identifying 21 cases that had at least one variable with an extreme outlier. To accommodate for these outliers, the researchers utilized a Windorized mean based on adjacent data points (Barnett & Lewis, 1994; Osborne & Overbay, 2004). Next, the assumptions associated with structural equation modeling (SEM) were tested (e.g., normality and multicollinearity; Hair, Black, Babin, Anderson, & Tatham, 2006; Tabachnick & Fidell, 2007). Multicollinearity was not present with these data; however, the data violated the assumption of normality of a single composite variable (e.g., devaluing clients scale on the CBI). Researchers conducted descriptive analyses of the data using the statistical software SPSS. Table 1 presents the means, standard deviations and correlations for the study variables.


Model Testing

This correlational investigation utilized a two-step SEM method (Kline, 2011) to examine the research hypothesis employing AMOS (version 20) software. The first step included a confirmatory factor analysis (CFA) to inspect the measurement model of burnout and its fit with the data. Then, a structural model was developed based on the measurement model. The measurement model and structural model were appraised using model fit indices, standardized residual covariances, standardized factorial loadings and standardized regression estimates (Byrne, 2010; Kline, 2011). Modifications to the models were made as needed (Kline, 2011). Both the measurement and the structural models employed the use of maximum likelihood estimation technique despite the presence of non-normality based on recommendations from the literature (Curran, West, & Finch, 1996; Hu, Bentler, & Kano, 1992; Lei & Lomax 2005; Olsson, Foss, Troye, & Howell, 2000).






Table 1 Correlations among measures of direct student services, perceived stress, and burnout



















Percent of Time





Perceived Stress



















































Note. N = 926. All correlations (r) were statistically significant (p < .001). Counseling = frequency of direct counseling services, curriculum = frequency of direct curriculum services, percent of time = percent of time in direct services to students, NEW = negative work environment, DC = devaluing client, DPL = deterioration in personal life.



Multiple fit indices were examined to determine the goodness of fit for the measurement model and structural model (Hu & Bentler, 1999; Kline, 2011; Weston & Gore, 2006). The fit indices that were used include: (a) chi-square, (b) comparative fit index (CFI), (c) goodness of fit (GFI), (d) standardized root mean square residual (SRMSR), and (e) root mean square error of approximation (RMSEA). Furthermore, we consulted the normed fit index (NFI) and Tucker-Lewis index (TLI) because they are more robust to non-normal data as compared to other indices (Lei & Lomax, 2005). For a detailed description of these fit indices, readers can review the works of Hu and Bentler (1999), Kline (2011), and Weston and Gore (2006). We used these fit indices to establish a diverse view of model fit.


     Measurement model. First, we employed a CFA model to examine the latent variable representing burnout (Lee et al., 2007). The research team totaled each subscale on the CBIs to develop a composite score for each domain. The initial measurement model for burnout produced acceptable standardized factor loadings ranging from .41 (devaluing client) to .57 (incompetence), .62 (negative work environment), .77 (deterioration in personal life), and .82 (exhaustion). Furthermore, all fit indices for the measurement model indicated an adequate fitting model except chi-square, RMSEA, and TLI: χ2 (df = 5, N = 926) = 107.07, p < .001; GFI = .96; CFI = .92; RMSEA = .15; SRMR = .06; NFI = .92; TLI = .85. Therefore, we consulted the modification indices and standardized residual covariance matrix and tested a new CFA based upon these consultations.


The modifications indices indicated the need to correlate the error terms for incompetence and devaluing client. The resulting model produced a model in which all fit indices indicated an adequate fitting model: χ2 (df = 4, N = 926) = 12.03, p = .02; GFI = .99; CFI = .99; RMSEA = .05; SRMR = .02; NFI = .99; TLI = .99. Further inspection of the standardized factor loadings for the model indicated they were all acceptable except for the factor loading for devaluing client, which dropped to .36 (below .40; Stevens, 1992). While these modifications improved the overall fit of the CFA, the correlation of incompetence and devaluing client has no theoretical justification (Byrne, 2010). In addition, the correlation of the error terms for incompetence and devaluing client produced a standardized factor loading below the noted standard of .40 (Kline, 2011; Stevens, 1992). Subsequently, we removed the subscale of devaluating client given: (a) the low factor loading produced after modification of the initial model, and (b) the lack of normality in the composite score.


Next, we examined the new modified measurement model that included the removal of the subscale devaluing client. The resulting model (see Figure 1) produced a model in which all fit indices indicated a good fitting model: χ2 (df = 2, N = 926) = 8.25, p = .02; GFI = .99; CFI = .99; RMSEA = .06; SRMR = .02; NFI = .99; TLI = .98. The modified measurement model for burnout produced acceptable standardized factor loadings ranging from .53 (incompetence) to .63 (negative work environment), .77 (deterioration in personal life), and .85 (exhaustion). In review of the model fit indices and standardized factor loadings, we deemed the measurement model acceptable for use in the structural model.


     Structural model. We developed the structural model (see Figure 1) based on a review of the literature, and it was theorized in this model that school counselors’ perceived stress correlates to school counselors’ burnout and contributes to the frequency with which they provide direct student services. In addition, this model tested the hypothesized model that school counselors’ burnout contributes to their frequency of direct student services. The structural model includes the measurement model previously tested that consisted of the latent variable of burnout. School counselors’ perceived stress and burnout were defined as exogenous or independent variables. Perceived stress was a manifest variable consisting of participants’ composite scores on the PSS (Cohen et al., 1983).


Additionally, we defined the manifest variables of percentage of time at work providing direct services to students, direct curriculum activities, and direct counseling activities as the endogenous or dependent variables that measure participants’ facilitation of direct student services. The variable of percentage of time at work providing direct services to students was a single demographic item reported by participants, while direct curriculum activities and direct counseling activities were the participants’ composite scores derived from subscales on the SCARS (Scarborough, 2005). In addition, the error terms of the direct student services variables—percentage of time at work providing direct services to students, direct curriculum activities and direct counseling activities—were correlated given that they measure similar constructs.


An examination of the structural model indicated a strong goodness of fit for all fit indices except for chi-square: χ2 (df = 14, N = 926) = 108.37, p < .001; GFI = .97; CFI = .96; RMSEA = .07; SRMR = .04; NFI = .95; TLI = .91. The researchers deemed the structural model as suitable with these data despite the significant chi-square (Henson, 2006; Kline, 2011; Weston & Gore, 2006). A closer examination of the standardized regression weights identified that school counselors’ burnout scores contributed to 12% (β = -.35, p < .001) of the variance in their direct counseling activities and 5% (β = -.22, p < .001) of the variance in their direct curriculum activities. Furthermore, school counselors’ burnout scores contributed to 6% (β = -.24, p < .001) of the variance in percentage of time at work providing direct services to students. Perceived stress did not contribute to direct counseling activities (β = .11, p = .04), direct curriculum activities (β = .06, p = .31), and percentage of time at work providing direct services to students (β = .04, p = .51). In addition, perceived stress and burnout produced a statistically significant correlation (β = .75, p < .001; 56% of the variance explained).


The structural model (Figure 1) indicates that school counselors’ level of counselor burnout had a negative contribution to the frequency of their direct counseling activities, direct curriculum activities and percentage of time at work providing direct services to students. However, it should be noted that the effect sizes of these findings were small to medium (Sink & Stroh, 2006). An additional finding from this investigation was that the perceived stress correlated with burnout with a large effect size (Sink & Stroh, 2006); however, perceived stress did not have a statistically significant contribution to school counselors’ direct counseling activities, direct curriculum activities, and percentage of time at work providing direct services to students.



Figure 1. Final hypothesized structural model depicting the relationship between school counselors’ (N = 926) perceived stress, burnout, and direct student services.




This study examined the relationship between school counselors’ reported burnout, perceived stress and frequency of direct student services. The findings indicated burnout was a statistically significant contributor to the frequency of direct counseling services (β = -.35; medium effect size) and direct curriculum services (β = -.22; small to medium effect size). Furthermore, the findings identified that burnout was a significant contributor to the participants’ report of the percentage of time they spend on their job working directly with students (β = -.24; small to medium effect size). Although the results should be interpreted with some level of caution, we found that burnout also had a statistically significant relationship to frequency of direct student services with increased levels of burnout relating to lower levels of direct student services. Nonetheless, these findings are not surprising considering the literature on burnout emphasizes the important role burnout plays on the effort one places on their job, with individuals presenting with higher burnout typically having lower investment interest in their job (Garman, Corrigan, & Morris, 2002; Landrum, Knight, & Flynn, 2012; Maslach, 2003). While the findings support the literature on the role of burnout, they also bring attention to the possibility that burnout does not have a strong relationship to school counselors’ facilitation of direct counseling services as noted by the small effect size.


An interesting finding was that school counselors’ degree of perceived stress did not contribute to the direct student services variables and yet did correlate with burnout. In fact, the relationship between perceived stress and counselor burnout had a large effect size, with 56% of the variance among these variables explained by their relationship. This finding accentuates the difference between the constructs of burnout and stress because burnout had a statistically significant relationship with the direct student services variables and stress did not, despite the strength of the relationship between burnout and stress. One interpretation of this finding is that school counselors’ ability to manage and cope with stress permits them to complete their job functions, whereas burnout may be more challenging to overcome. Furthermore, scholars state that prolonged exposure to stress worsens or cultivates burnout (Cordes & Dougherty, 1993; Schaufeli & Enzmann, 1998). This finding is logical given the theory behind burnout (Lee et al., 2007; Maslach, 2003); yet, this is one of only a few studies (McCarthy et al., 2010; Wilkerson & Bellini, 2006) in the school counseling literature to examine this relationship. However, these results need further exploration. As McCarthy et al. (2010) noted, the construct of stress is multidimensional (includes appraisal of resources and demands) and the PSS (Cohen et al., 1983) is a single-dimension scale. Therefore, a scale that examines stress in a multifaceted manner may produce different results.


An additional finding worth discussion involves the measurement model of the CBI (Lee et al., 2007). Specifically, this study found that the construct of devaluing client did not fit with the data. Furthermore, participants reported low scores regarding the devaluing client scale, as indicated by the descriptive statistics. The devaluing client subscale also was the only subscale on the CBI that was not normally distributed. These results were similar to Gnilka et al.’s (2015) findings that indicated school counselors are likely to maintain high levels of empathy and positive regard for their students. These findings may indicate that the devaluing clients subscale may not reflect symptoms of burnout for school counselors. This is a promising finding as it suggests that school counselors do not develop a negative perspective of students because of the negative consequences of their job.


The descriptive statistics from this investigation also provide some noteworthy information. First, participants reported moderate to low levels of burnout across the five factors of the CBI (Lee et al., 2007), with exhaustion having the highest mean score. These results are consistent with prior research (Butler & Constantine, 2005; Lambie, 2007; Wachter et al., 2008; Wilkerson & Bellini, 2006) on burnout and indicate that, overall, school counselors report low levels of burnout. An additional finding was that school counselors reported a low level of perceived stress, which is surprising given the challenge of role ambiguity, confusion and conflict (Burnham & Jackson, 2000; Culbreth et al., 2005; Lambie, 2007; Scarborough & Culbreth, 2008). However, school counselors have reported low levels of stress in other research (e.g., McCarthy et al., 2010; Rayle, 2006). The last noteworthy finding from the descriptive statistics was the measures of direct student services. This investigation was one of the first to focus specifically on the topic of direct student services versus other aspects of school counselors’ roles. This study found that school counselors reported that, on average, they spend over half their time working directly with students. In addition, they reported high frequencies for facilitating both curriculum and counseling activities. These findings are promising and consistent with other research examining these constructs (Mullen & Lambie, 2016; Scarborough & Culbreth, 2005; Shillingford & Lambie, 2010). Overall, the results from this study provide new and novel information for the school counseling discipline.


Limitations and Implications for Future Research

Readers should interpret these findings within the context of their limitations. Some limitations from this study include: (a) associational research using correlation statistics does not establish cause and effect relationships; (b) the response rate, although high as compared to other studies with similar methods, is low; and (c) the generalizability of these findings is limited by the sampling procedures (e.g., only sampled ASCA members; Gall et al., 2007). In addition, participants who respond to surveys may have different characteristics as compared to those school counselors who chose not to participate (Gall et al., 2007).


The findings from this study have implications for future research. A prominent direction for future research is the examination of the relationship between stress and programmatic service delivery, including direct student services. This study identified that perceived stress has no relationship with direct service delivery, but a multidimensional measure of stress (McCarthy & Lambert, 2008) may produce different results. Similarly, this study found that perceived stress relates to higher levels of burnout and supports the theory that chronic stress relates to increased burnout. Future research might further confirm these findings.


Another relevant future research implication is exploring factors that prevent or mediate the contribution of burnout to school counselor service delivery, considering this investigation found a significant relationship between these constructs. A variety of mechanisms may serve as buffers between burnout and programmatic service delivery, such as coping skills, career-sustaining behaviors, emotional intelligence, grit, or self-efficacy. Nonetheless, the identification of preventative skills or personal traits that inhibit the effects of burnout may lead to interventions to support school counselors’ work. Future research also can examine training interventions that target school counselors’ susceptibility to burnout or stress. A final research implication is the need to replicate and confirm our findings. Researchers might consider replicating this study with similar or different measures and data collection methods.


Implications for School Counseling Practitioners and Supervisors

The degree of perceived stress for participants in this study had a positive correlation with their degree of burnout. Furthermore, participants’ burnout negatively contributed to their level of direct student services. While this study included several limitations, these findings provide more evidence for the positive relationship between stress and burnout, in addition to the negative contribution burnout can have on the job functions of school counselors. In an effort to support direct student services, it would behoove school counselors to take steps to increase their awareness about their well-being, including symptoms of burnout, and seek support to address concerns as they arise. Additionally, school counselors’ failure to address burnout is an ethical concern (American Counseling Association, 2014). School counselors could utilize a self-assessment (i.e., Counselor Burnout Inventory [Lee et al., 2007] or Professional Quality of Life Scale [Stamm, 2010]) to examine their level of burnout and subsequently address their work functions and lifestyle to alleviate symptoms.


As Moyer (2011) pointed out, supervision plays a vital role in school counselor development and can be a way to alleviate burnout. Thus, supervisors can provide opportunities for school counselors to learn ways to assess their well-being with the aim of developing career-sustaining behaviors to prevent burnout. For example, supervisors can inform school counselors of available screening measures and provide resources to aid in the development of career-sustaining behaviors. Similarly, supervisors can create activities (Lambie, 2006) that assess school counselors’ well-being, which allows counselors to address negative feelings. Efforts made to prevent burnout may increase the chances of school counselors performing direct student services. Higher rates of direct student services, such as individual and group counseling, also may lead to better educational outcomes for students (Lapan, 2012).


In an effort to reduce school counselors’ burnout and potentially increase their delivery of direct student services, practitioners and supervisors can initiate wellness-related activities. Butler and Constantine (2005) noted that peer supervision or consultation along with social support from colleagues and administrators might be helpful for reducing the effects of burnout. Furthermore, Lawson and Myers (2011) reported on the highest rated career-sustaining behavior, which provides potential to support the wellness of school counseling practitioners. As Meyer and Ponton (2006) noted, counselors as a whole tend to put their own wellness to the side in order to provide services to their clients. Therefore, another consideration for school districts and school counseling organizations is to offer wellness-focused training that could raise attention to counselors’ level of stress and burnout and provide strategies to enhance their wellness. Additionally, school counselors should remember to advocate for the profession and for themselves (Young & Lambie, 2007). It is important that administrators understand the critical wellness needs of school counselors, and school counselors should be among the first to advocate for this cause. As these findings indicate, there is a relationship between burnout and the quality of services offered by school counselors. Therefore, it is important that counselors “learn to be their own advocates and help dysfunctional workplaces become well” (Young & Lambie, 2007, p. 99).


In summary, this study examined the association of practicing school counselors’ degree of burnout, perceived stress and frequency of direct student services. The findings indicated that higher levels of burnout contribute to a decreased frequency of direct student services. Furthermore, school counselors’ perceived stress does not contribute to their facilitation of direct student services, but was positively associated with burnout. Overall, these findings are encouraging because the descriptive statistics indicate that school counselors operate at a low level of burnout and perceived stress and provide a moderate to high frequency of direct student services.



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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Patrick R. Mullen, NCC, is an Assistant Professor at the College of William and Mary. Daniel Gutierrez, NCC, is an Assistant Professor at the University of North Carolina – Charlotte. Correspondence can be addressed to Patrick Mullen, School of Education, P.O. Box 8795, College of William & Mary, Williamsburg, VA  23188, prmullen@wm.edu.