Curtis Garner, Brenda Freeman, Roger Stewart, Ken Coll
Tools to assess the dispositions of counselor education applicants at the point of program admission are important as mechanisms to screen entrance into the profession. The authors developed the Professional Disposition Competence Assessment—Revised Admission (PDCA-RA) as a screening tool for dispositional assessment in admissions interviews. In this study, 70 participants engaged in a video-based training protocol designed to increase the interrater reliability of the PDCA-RA. An intraclass correlations coefficient was calculated as an index of interrater reliability. Cronbach’s alpha coefficients were calculated for internal consistency, and Fleiss’ kappa, free-marginal kappa, and percent of agreement were calculated for absolute agreement. Calculations were made for pretest and posttest scores. Results of the study suggest that the PDCA-RA demonstrates “good” reliability in terms of interrater reliability and “excellent” reliability in terms of internal consistency. The video-based training improved interrater reliability.
Keywords: dispositions, counselor education, interrater reliability, counseling admissions, PDCA-RA
Beyond ethical codes and standardized education requirements, one criterion understood to be a demarcation of a profession is that it controls entry into its occupation (Miller, 2006). The stature of any profession is heavily influenced by the collective quality, preparation, and professional fit of those who are allowed to enter the profession. In the profession of counseling, counselor preparation programs, practicing counselors, field site supervisors, and state licensure boards share the overarching charge to screen for the profession (Freeman et al., 2016), but counselor educators alone bear the responsibility of initial screening of potential new entrants into the profession. The funnel of individuals seeking entrance into the profession begins with admission to graduate programs. This responsibility is a solemn one because post-admission gatekeeping can lead to high-stakes legal disputes (Dugger & Francis, 2014; Hutchens et al., 2013; McAdams et al., 2007).
Similar to other graduate programs, criteria for entrance into counselor preparation programs generally incorporate academic and career factors, but unlike many other graduate programs, the dispositions (traits and characteristics) of applicants are also critical factors for identifying appropriate candidates for the profession (Hernández et al., 2010). The use of admissions interviews is a common method for observing dispositions (Swank & Smith-Adcock, 2014). Characteristics such as interpersonal skills, warmth, emotional stability, and self-awareness are examples of traits deemed important to many counseling academic programs (Crawford & Gilroy, 2013; McCaughan & Hill, 2015), though counselor educators lack agreement about which dispositions should be screened at admission (Bryant et al., 2013).
Once applicants have been accepted into a counselor education program, if problematic dispositional issues arise the American Counseling Association (ACA) ethical codes require remediation (ACA, 2014), which is sometimes followed by suspension or dismissal. Therefore, gatekeeping, defined as the process of deterring program graduation of those lacking sufficient knowledge or skills (Koerin & Miller, 1995), begins at the point of program screening and admission (Kerl & Eichler, 2005). Bryant et al. (2013) emphasized that effective screening of applicants prior to formal admission into the academic program may greatly reduce the need to address problematic student behaviors after admission.
In addition to conducting admissions screening as a form of gatekeeping, the courts are more likely to support universities in admissions-related legal disputes if screening policies, standards for admission, and admission procedures are clear and fair (Cole, 1991). Legal research also underscores the importance of programs communicating clearly with students about the expected dispositions and other criteria from admission through exit (McCaughan & Hill, 2015). Reliable admissions tools designed to assess dispositions represent one method of showing fidelity in implementing policies (Hutchens et al., 2013). Despite the research support for sound structures to scaffold the admissions process, assessments with published psychometric properties measuring dispositions in admissions interviews are scarce (Hernández et al., 2010).
Jonsson and Svingby (2007) noted that a number of forms of reliability and validity are important in establishing the psychometric properties of admissions tools, but when multiple raters are involved, such as in the admissions process, interrater reliability for rubrics is particularly essential. Specific training in the tool is critical to improving interrater reliability (Jonsson & Svingby, 2007). Video training protocols to increase interrater reliability are becoming more important in professional dispositional research (Kopenhaver Haidet et al., 2009; Rosen et al., 2008). The use of video technology to train raters to capture behavioral observations has two advantages: the opportunity for admissions personnel to practice admissions interview ratings prior to real-time observations, and the relative ease of using modern, sophisticated recording equipment (Kopenhaver Haidet et al., 2009).
Admissions Processes and Criteria
Overwhelmingly, admission criteria and procedures for counselor education programs have focused upon undergraduate grade point average (GPA); standardized test scores, such as the Graduate Record Examination (GRE) or the Miller Analogies Test (MAT); a personal interview; and some form of personal statement (Bryant et al., 2013). Such procedures have been shown to be reasonably predictive of academic success, but less so for counselor development (Smaby et al., 2005). Some programs have utilized Carkhuff’s Rating Scale (Carkhuff, 1969) or Truax’s Relationship Questionnaire (Truax & Carkhuff, 1967) to measure applicants’ ability to communicate the conditions of empathy, genuineness, and respect effectively (Hernández et al., 2010; Swank & Smith-Adcock, 2014). Carkhuff’s Rating Scale and Truax’s Relationship Questionnaire have been found to exhibit good interrater reliability and, when correlated with one another, have been found to exhibit considerable overlap (Engram & Vandergoot, 1978).
Following the gatekeeping dispute in Ward v. Wilbanks (2010), in which a graduate student in counselor education refused to work with a gay client, and the ensuing litigation upon that student’s dismissal from their program, the need for a reliable method for evaluating counseling student dispositions has become increasingly apparent. This high-profile legal case also highlighted the need to monitor and document student dispositions (Dugger & Francis, 2014; McAdams et al., 2007). Correspondingly, in 2009 the Council for Accreditation of Counseling and Related Educational Programs (CACREP) released standards that made monitoring student dispositions a mandatory aspect of program evaluation. In the 2016 CACREP standards the expectation for the assessment of counselor-in-training dispositions was expanded to include the monitoring of dispositions at multiple points over the duration of time students are enrolled in a counselor education program. The accreditation expectations for screening at the point of admission are found in Section I.L., where the standards delineate the expectation that counseling programs consider dispositions (CACREP, 2015). Dispositions for consideration include relationship skills and cultural sensitivity.
As the need for dispositional appraisal has become increasingly imperative in the counselor education profession, there have been various efforts to design specific approaches to assess student dispositions (Frame & Stevens-Smith, 1995; Kerl et al., 2002; Lumadue & Duffey, 1999; McAdams et al., 2007; Redekop & Wlazelek, 2012; Williams et al., 2014). One early approach was the utilization of standardized personality tests (Demos & Zuwaylif, 1966; Utley Buensuceso, 2008). However, the use of personality tests fell into disfavor because of the potential for conflicts with the Americans with Disabilities Act (U.S. Department of Justice, 2010) as well as for their inherent deficit orientation. Consequently, the use of standardized tests has been generally replaced by rating scales and rubrics (Panadero & Jonsson, 2013).
One reason that rubrics were considered superior to rating scales was their transparency (Panadero & Jonsson, 2013). Transparency empowers students by equipping them with an understanding of expectations for performance prior to their creating a product or performing a skill. Rubrics also have greater potential to align with learning outcomes and they provide useful direct feedback to students (Alexander & Praeger, 2009; Panadero & Jonsson, 2013).
Examples of dispositional assessments for counselors include the Counselor Characteristics Inventory (Pope, 1996), an inventory that assesses personality characteristics of effective counselors. Also, Spurgeon et al. (2012) described a process that includes a Likert-style assessment of dispositional traits. In addition, Swank et al. (2012) developed the Counseling Competencies Scale (CCS), a tool for measuring counselor competence. Frame and Stevens-Smith (1995) developed a 5-point Personal Characteristics Evaluation Form, and finally, Lumadue and Duffey (1999) published a Professional Performance Fitness Evaluation to evaluate specific behaviors of pre-professional counselors. Few studies of the reliability and validity of the tools were found in published research, especially related to admissions. However, some do have limited published psychometric research and in some cases norms (Flynn & Hays, 2015; Pope, 1996; Swank et al., 2012; Taub et al., 2011).
One example of a dispositional tool for counselor education with published psychometrics is the Counselor Personality Assessment (CPA) developed by Halinski (2010). The CPA is a 28-item scale reporting a Cronbach’s alpha reliability score of .82. Another tool, the CCS (Swank et al. 2012), is a 32-item rubric for measuring counseling skills, professional conduct, and professional dispositions in practicum. Cronbach’s alpha for the CCS was reported at .93, and interrater reliability was reported at .57. Criterion validity was established by correlating the CCS score with the semester grade and was reported as moderate. The available psychometric data for the CPA and CCS represent exceptions. In general, lack of psychometric information may result in limited confidence in available assessment tools for appraising counselor student dispositions.
Interrater reliability, essentially the extent to which the raters assign the same scores when observing the same behaviors (McHugh, 2012), is critical for fairness to applicants in counseling admissions interviews. Gwet (2014) stated, “If the inter-rater reliability is high, then raters can be used interchangeably without the researcher having to worry about the categorization being affected by a significant rater factor. Interchangeability of raters is what justifies the importance of inter-rater reliability” (p. 4). Consistency ensures that the data collected are realistic for practical use. When interrater reliability is poor, interviews conducted by overly critical raters (hawks) naturally lead to negative bias against applicants when compared within the same applicant pool with the scores from interviews rated by less critical raters (doves). Epstein and Synhorst (2008) discussed interrater reliability as an approximation in which different people rate the same behavior in the same way. Thus, interrater reliability can also be understood as rater consensus.
Purpose of the Present Study
Effectively screening and selecting new entrants is one of the hallmarks that distinguishes a profession. Unfortunately, there is a dearth of available literature on assessment tools for rating admissions interviews. Further, lack of information on the reliability of the tools that exist represents a significant deficiency in professional literature (Johnson & Campbell, 2002). The Professional Disposition Competence Assessment—Revised Admission (PDCA-RA; Freeman & Garner, 2017; Garner et al., 2016) is a global rubric designed to assess applicant dispositions in brief graduate program interviews. The PDCA-RA includes a video training protocol developed to facilitate consistency across raters in scoring admissions interviews on dispositional domains.
The purpose of the study was to examine the internal stability and the interrater reliability of the PDCA-RA. The rationale for the study was that no similar rubrics assessing dispositions at admissions using training videos were found in published research, suggesting a gap in the literature. Interrater reliability was the key focus of this study because of the importance of interrater reliability for rubrics utilized in situations with multiple raters, a typical scenario for counselor education admissions processes.
Raters for the study included 70 counselor educators, counseling doctoral students, adjunct faculty, and site supervisors. Counselor educators, doctoral students, and adjunct faculty at two universities were asked to participate in trainings on the new admissions screening tool. Site supervisors providing supervision for practicum and internship students at the two universities were offered training in the PDCA-RA as a component of continued professional development to maintain their supervision status. Training in both instances was free and included professional development credits. Informed consent for participation was obtained from all participants in accordance with ACA ethical codes (ACA, 2014) and IRB oversight at both universities. All participants in the study fully completed the PDCA-RA video-based training. The mean age of the raters was 43.9 (SD = 11.4, range 24–72). Sixty-four percent identified as female and 36% identified as male. Mean average years of experience indicated as a faculty or field supervisor was 12.2 (SD = 9.7, range 1–50). Ninety-three percent identified as White/Caucasian, 6% as Latino/a, and 1% as other ethnicity.
The counselor educators (27% of the sample) were primarily from two CACREP-accredited counseling programs in the Western United States. Participating universities included one private university and a state research university, both with CACREP-accredited programs. Counselor education doctoral students and adjunct faculty participants comprised 7% of the sample. The doctoral students participated in the training because they were involved as raters of master’s-level counselor education applicants in the admissions process at one institution. The remaining 66% of the participants were field site supervisors. Because field site supervisors were involved in gatekeeping, attending training in dispositional assessment was natural to their role as internship site supervisors.
The PDCA-RA was developed on the basis of the Professional Disposition Competence Assessment (PDCA; Garner et al., 2016). The PDCA, a dispositional gatekeeping tool, was revised to the Professional Disposition Competence Assessment-Revised (PDCA-R) after several rounds of use and with feedback from expert panels (Freeman & Garner, 2017). Advice from legal counsel was also reflected in the revision of the PDCA to the PDCA-R. The PDCA-R was originally used for both gatekeeping and admissions purposes, but it was determined that the PDCA-R was best used for gatekeeping, not for admissions screening, because the tool implied that the rater had prior knowledge of the student. Because this is often not the case in admissions screening, the PDCA-RA was developed.
The PDCA, PDCA-R, and PDCA-RA were conceptualized and developed through a comprehensive review of the literature, several rounds of field testing, and adjustments from expert faculty panels at two institutions. In addition to counseling literature on impairment and expert panel feedback, the Five-Factor Model, often referred to as the “Big Five” (Costa & McCrae, 1992), influenced three of the nine dispositional items. The Five-Factor Model consists of five personality traits consistently associated with positive mental health, academic success, and healthy habits and attitudes across the life span: Extraversion, Agreeableness, Conscientiousness, Emotional Stability, and Openness. The PDCA-RA dispositions are identical to the PDCA-R, with the exception of the disposition of Ethics. Ethics was removed from the PDCA-RA because the description assumed knowledge of professional ethical standards, a doubtful expectation for program applicants with no prior training in counseling. The behavioral descriptions in the PDCA-RA were narrowed so they described only those behaviors that can be observed in admissions interviews with no prior knowledge of the applicants. In addition, the rubric item descriptions were shortened to align with the practical context of brief (20- to 30-minute) admissions interviews in which there may be limited time for in-depth assessment.
If dispositions are thought of as traits, as per the definition of dispositions in the CACREP glossary (CACREP, 2015), the PDCA-RA is not technically directly measuring dispositions. Based upon advice from legal counsel, as well as the practicality of assessing applicants during short admissions interviews, the PDCA-RA assessed behaviors associated with dispositions and not the actual dispositions. Behaviors identified for each disposition can be observed during a short admissions interview, whereas personality traits would require a more in-depth assessment approach, one that counselor educators fear might be found legally problematic (Freeman et al., 2019; Schuermann et al., 2018).
The nine dispositions assessed in terms of observable behaviors via the rubric are Conscientiousness, Coping and Self-Care, Openness, Cooperativeness, Moral Reasoning, Interpersonal Skills, Cultural Sensitivity, Self-Awareness, and Emotional Stability. Each disposition in the PDCA-RA is rated on a scale of three levels—developing, meets expectation, and above expectation. The PDCA-RA is described in more detail in a manual that includes the tools as well as three suggested admissions questions for each of the nine dispositions (Freeman & Garner, 2017). The measure of internal consistency for faculty ratings of the original PDCA rubric was a Cronbach’s alpha estimated at .94 (Garner et al., 2016). Cronbach’s alpha for self-ratings was .82, and Cronbach’s alpha for peer ratings was .89. The straightforward modifications from the original PDCA to the PDCA-RA were minimal and unlikely to significantly affect these measures of internal consistency.
A video-based training protocol was developed for the purpose of training faculty in counselor education programs, doctoral students, site supervisors, and other admissions raters to use the PDCA-RA to assess the dispositions of graduate program applicants (Freeman & Garner, 2017; Garner et al., 2016). The video was presented to participants by a trainer. The trainer also greeted participants, obtained informed consent, passed out PDCA-RA forms when prompted by the training video, and collected completed PDCA-RA forms for later analysis. Training in the use of the PDCA-RA was important not only as a mechanism to establish interrater reliability but also as a means of informing adjustments to the tool during its initial iterative development process. Development of the video-based training protocol progressed through several stages. At first, the original 90-minute training consisted of a faculty team of seven working together as a group to read and discuss each disposition, followed by each faculty viewing an admissions interview video and rating the applicant independently. Faculty then discussed their ratings, leading to subtle adjustments in the rubric item descriptions. Additional benefits to the training were an increase in faculty self-awareness of dove and hawk tendencies when rating admissions applicants and self-awareness associated with interview bias. With continued training and feedback, the original training protocol was significantly improved.
To complete the next step in the creation of the video-based training protocol, counseling student volunteers were offered a minimal incentive to come to the film studio, and after signing waivers to allow the film clips to be used, the student volunteers were asked to respond to various admissions interview questions. The faculty filming the students instructed them to “give a strong answer” or “give a weak answer.” The researchers treated all responses as unscripted role plays. The questions asked by the interviewer for each disposition were those found in the PDCA-RA materials (Freeman & Garner, 2017). Finally, the authors and developers of the training video reviewed over 100 film clips, removed those in which the acting interfered with the purpose of the video, and rated the remaining clips using the PDCA-RA, resulting in ratings of 1, 3, or 5. These numerical ratings corresponded to descriptive ratings of developing, meets expectation, and above expectation, respectively. Clips in which the researchers found the rating to be difficult were removed from consideration. In selecting the final 18 clips (two for each of nine dispositions), the researchers considered diversity in age, ethnicity, gender, and disability of the student volunteers. The goal was to create video clips of student volunteers with diverse characteristics.
The result was a video-based training protocol that could still be completed by trainees in 90 to 120 minutes. The video training protocol began with an introduction to the PDCA-RA, followed by prompts to rate the video-recorded vignettes using the PDCA-RA prior to receiving training. This initial rating of the vignettes was considered the pretest condition. Training on the application of the PDCA-RA to the vignettes was next. Training included revealing ideal scores as determined by the authors, the reasoning behind the scoring, and opportunities to discuss scoring among participants. Following the training on the PDCA-RA, participants were, once again, given the PDCA-RA rubric along with a new set of video-recorded vignettes. This was considered the posttest condition. Participants were asked to rate the new vignettes using the PDCA-RA.
The video-based training protocol, designed for use in small groups, allowed for group discussion of ratings after each participant completed the PDCA-RA independently. This was indicated by a written message on the video reading, “Pause video for discussion.” The training tape ended with a narrator discussion of how to use the PDCA-RA in actual admissions interviews, including comments on cultural sensitivity in admissions interviews.
The video-based training protocol was used as the means of training participants in dispositional assessment. The purpose of the trainings was to increase consistency of admissions raters in evaluating the admissions interviews of applicants to a master’s-level counselor education program. Typically, participants completed the video training in small groups consisting of approximately six to 10 people. In addition to viewing the training video, participants also took part in group discussion and established a consensus of opinion on group ratings of video clips. Coming to a consensus on ratings, which also included feedback on rubric items and video clips, was an important aspect of the training.
The PDCA-RA scores from the counselor education faculty, adjunct faculty, doctoral students, and site supervisors’ ratings of the vignettes before training were used as the pretest or baseline interrater reliability. The PDCA-RA scores after participants were trained in the tool were used as the posttest. The intraclass correlation coefficient (ICC) was calculated as a measure of interrater reliability. Interrater reliability correlations quantify rater subjectivity (Herman et al., 1992). The ICC was calculated for pretest and posttest scores. Cronbach’s alpha coefficients were calculated for internal consistency, and Fleiss’ kappa (κ) was calculated for absolute agreement. In addition, Fleiss’ free-marginal kappa (κfree) and percent overall agreement were calculated. Calculations were made for both the pretest and posttest ratings, and a t-test was conducted, using SPSS, to determine whether training improved interrater reliability.
The ICC estimates and associated 95% confidence intervals were calculated using SPSS statistical package version 23 and based on an individual rating, absolute agreement, 2-way random-effects model. ICC single measures for absolute agreement were calculated for the pretest administration of the PDCA-RA at .53 (95% CI [0.333–0.807]). The ICC single measures for absolute agreement were calculated for the posttest administration of the PDCA-RA at .76 (95% CI [0.582–0.920]). Cronbach’s alpha was calculated at .99 for both pretest and posttest scores. Pretest and posttest ICCs were compared using a t-test with an a priori significance level set at .05. The test was significant (p < .05), suggesting that there was a difference between the pretest and posttest reliability, with reliability improving from the “moderate” range to the “good” range (Koo & Li, 2016) with training.
Using Excel, kappa (κ) was calculated as a measure of overall agreement for pretest and posttest scores. This particular kappa was extended by Fleiss (1971) and accommodates multiple raters like those rating the PDCA-RA. Assumptions underpinning Fleiss’ kappa include categorical data (i.e., nominal or ordinal) with mutually exclusive categories, symmetrical cross-tabulations, and independence of raters. Data in this study met all assumptions. Data was ordinal with three mutually exclusive response categories for each dispositional area assessed, which resulted in all cross-tabulations being symmetrical. Although raters were trained in a collaborative setting where discussions about ratings were fostered, when the actual ratings of study participants occurred, raters did not discuss their ratings with others and were thus independent of one another. Pretest scores for the nine rubric items reflected a κ of .33, fair agreement according to Landis and Koch (1977). After training, posttest scores on the nine items reflected a κ of .55, moderate agreement according to Landis and Koch.
As an additional analysis, percent overall agreement and κfree was calculated. κfree is appropriate when raters do not know how many cases should be distributed into each category. In addition, κfree is resistant to influence by prevalence and bias (Randolph, 2005). The percent of overall agreement is the measure of agreement between raters and historically has also been used to calculate interrater reliability (McHugh, 2012). Table 1 illustrates that the κfree for the pretest was .36 while the percent of overall agreement was 57.6%. The posttest for the κfree was .56 and the percent of overall agreement was 70.4%. After examining the change in pretest to posttest calculations from both the κfree and the percent of overall agreement, both offer additional support for and provide evidence that training improved the agreement of dispositional ratings on the PDCA-RA.
Pre and Post Statistics: Percent Overall Agreement and Free-Marginal Fleiss’ Kappa
|Time of Rating
||Percent Overall Agreement
||95% CI for Free- Marginal Kappa
|Before Training: Pre
|After Training: Post
The overall κ, κfree and percent of agreement results were promising, but a comparison of the percent of correct responses (the response intended by the research team) by disposition showed that the ratings of correct responses decreased by more than 2% from pre- to posttesting for three dispositions (Openness, Cooperativeness, and Moral Reasoning). Because this was an unexpected finding, the research team analyzed the ratings for incorrect responses and learned that the raters appeared to be better able to discern the difference between a rating of 1 (developing) and 3 (meets expectation) than between 3 and 5 (above expectation). As a post-hoc analysis, we calculated the percent of agreement with the correct score, collapsing the 3 and 5 ratings. The percent of correct responses with dichotomous categories of 1 and a collapsed category for 3 and 5 are shown in Table 2. As is evident in Table 2, using the collapsed category, the percent of correct responses for eight of the nine dispositions improved from pretest to posttest. The percent of correct responses for one disposition, Cooperativeness, decreased by more than 2% from pretest to posttest.
Pre and Post Percent of Correct Responses by Disposition
Overall Agreement1, 3, 5
|Post Percent Overall Agreement
1, 3, 5
Overall Agreement1, 3 & 5
|Post Percent Overall Agreement
1, 3 & 5
|2. Coping & Self-Care
|5. Moral Reasoning
|6. Interpersonal Skills
|7. Cultural Sensitivity
|9. Emotional Stability
The results of the study suggest that the PDCA-RA has potential as a reliable instrument for assessing counseling applicants at the point of program admission. The PDCA-RA demonstrated strong reliability from the standpoint of internal consistency. The interrater reliability, as measured by the ICC, moved from the “moderate” to the “good” range with the application of the standardized training protocol.
The results of the study also provide evidence that counselor educators, supervisors, and doctoral students can improve their agreement on ratings of student dispositions with adequate and appropriate training. Multiple statistical techniques for measuring agreement, including the ICC, κ, κfree, and percent agreement measured under pre-training and post-training conditions demonstrated overall improvement in rater agreement with training. The observed post-training improvement in interrater reliability corroborates the literature, underscoring the necessity of training protocols as the pathway to improved interrater reliability (Jonsson & Svingby, 2007).
The results from the second analysis conducted through collapsing the meets expectation and above expectation categories suggest that the PDCA-RA has higher reliability as a tool to screen out inappropriate candidates than to distinguish excellence within the pool of acceptable candidates. For programs seeking to eliminate problematic applicants, the PDCA-RA could prove reliable. However, for academic programs with large numbers of applicants with an objective to accept a small group of students from a large group of acceptable candidates, the PDCA-RA may be less reliable from an interrater reliability perspective. The PDCA-RA item descriptions for above expectation need further consideration.
The percent of correct responses after training with collapsed categories was over 87% for seven of the nine dispositions. The results suggest that the PDCA-RA or the PDCA-RA training protocol needs revision on two dispositions, Cooperativeness and Self-Awareness. The decrease in correct responses to Cooperativeness may be due to a posttest interview with a higher level of difficulty than the pretest interview. The posttest percent was 87%, suggesting that overall the rubric descriptions functioned as acceptable with this sample of raters, though not excellent. The percent of correct ratings for Self-Awareness increased from pre- to posttesting, but only to 64% agreement. One explanation could be that the Self-Awareness rubric descriptions are behavioral (as recommended by legal counsel), yet Self-Awareness as a trait is difficult to describe in behavioral terms. This could leave raters confused about the difference between their intuitive sense of the self-awareness of the applicant and the narrow behavioral descriptions on the rubric. An alternative explanation is that there is a lack of agreement in the profession on the extent of self-awareness expected from students entering the academic program, leading some raters to find the applicant’s level of self-awareness acceptable, while others found the level unacceptable. In either case, the training protocol for the PDCA-RA and perhaps the rubric description need improvement. The 100% posttest agreement on the dichotomous categories for Openness and Cultural Awareness were encouraging, given the critical importance of these two dispositions (Freeman et al., 2019).
Interrater reliability is of paramount importance for the responsible use of rubrics. To improve the interrater reliability of the PDCA-RA, three issues may need to be addressed. First, the training protocol may need to be lengthened to encompass three rather than two opportunities to rate video clips. Second, structuring the discussion between raters with questions focusing attention on the gaps in ratings could be beneficial. Third, because alternate forms of the videos are being used in the training (different actors with different responses to the same question), a comparison of the complexity of the video clips should be conducted. It may be desirable to revise the training protocol to utilize less complex responses for Part 1 training, followed by equivalent complex interviews for Part 2 training, and more complex interview responses for Part 3. More complex responses, meaning the responses are partially descriptive of two categories on the rubric, are realistic to actual admissions interviews in the field.
In conducting trainings for the PDCA-RA, a potentially interesting observation was that raters appeared predisposed to using their own subjective experience to rate the video interviews instead of applying the item descriptions in the rubric. Often the trainers observed that the disposition title, such as Self-Awareness, triggered an automatic response of high rater confidence in their ability to rate self-awareness without carefully reading the rubric descriptions. The tendency of raters to believe they are “right” rather than applying a rubric description is a potential barrier for any dispositional measure.
Implications of the Study
The implications of this study relate primarily to counselor education programs. As evident from the review of literature, careful admissions processes are critical to prevent or diminish the number of gatekeeping and remediation situations that occur in academic programs after admission. In addition to the importance of fair admissions procedures from a legal perspective, the effort required of applicants to engage in the application process justifies the importance of developing fair processes in which acceptance or denial decisions are not based solely upon the subjectivity of faculty.
For those academic programs utilizing admissions interviews, one important implication of the study is that the results suggest that without training, raters will have high variability in their ratings of admissions applicants, as illustrated by the variability of the pretest scores in this study. Structuring the rating of admissions interviews by using an assessment is one method of mitigating the variability of faculty ratings of applicants. A holistic (global) rubric such as the PDCA-RA is unlikely to ever garner the almost perfect interrater reliability associated with analytic rubrics, but the PDCA-RA is available as one practical, field-tested tool with promising reliability to help facilitate transparent and fair admissions interview rating processes.
Limitations and Future Research
In light of the lack of an established list of professional dispositions, the PDCA-RA’s utility may be limited, as the selected dispositions may not align with the values of all counselor education programs. A second limiting factor is that the sample included both field site supervisors and faculty, and all participants were from the rural Western United States. The reliability of the tool is limited by the demographics of the sample. Another limitation was that the study’s pretest and posttest video clips, although similar, were different from one another. The initial decision to use different pretest and posttest video clips was based on an attempt to reduce the influence of testing as a threat to internal validity. However, this also introduced the possibility that either of the sets of video clips was inherently easier or more difficult to rate than the other. Further research would include randomly juxtaposing pretest and posttest video clips, or perhaps using the same video clips pre- and posttest to eliminate the possibility that differences in pretest and posttest video clips were responsible for the improvements in score reliability rather than the intended independent variable, the training. Another potential limitation to the results is that it is possible that some of the graduate students who were filmed in the vignettes may have been known by six of the faculty members from one of the institutions. The impact of this possibility was reduced by the use of multiple student actors, but prior knowledge of the student could have influenced raters’ scores.
A final issue for consideration is the decision to use site supervisors as raters for the research. Site supervisors more commonly utilize the PDCA-R rather than the PDCA-RA, the version specific to admissions screening. The PDCA-R is used by supervisors to monitor and to communicate with counselor educators and counseling program clinical personnel. Further, at least one of the counselor education programs utilizes site supervisors for the admissions process. The training protocol for both versions of the PDCA is the same, and with site supervisors routinely participating in the training, the decision was made to include site supervisors as raters. It is possible, however, that site supervisors may differ in their abilities to respond to the training protocol when compared to counselor educators, adjunct faculty, and doctoral students.
A possibility for future research is to measure the extent to which the improvement in reliability can be maintained over time. At this point, little is known about whether and how often educators and site supervisors would need training updates to function optimally as raters of student dispositions. Accordingly, rating reliability could be observed at intervals of 3 months, 6 months, or 1 year after training to monitor decay.
Future research is also needed to determine the extent to which the length of the training protocol influences interrater reliability. In addition, cultural and gender bias in the use of the PDCA-RA should be studied, as one criticism of rubrics is the potential for cultural bias.
As a tool for consistently rating counselor education program applicants, the PDCA-RA demonstrates potential, though more research needs to be conducted to increase the interrater reliability. Training improved the interrater reliability results but not to the extent that excellent interrater reliability was achieved. Adjusting the training protocol may be fruitful as a mechanism to improve interrater reliability.
There is a need for reliable admissions tools to assess dispositional behaviors of counseling program applicants. Interrater reliability is an important form of reliability in situations such as admissions interviews in which there are often multiple raters involved in the process. The importance of interrater reliability is founded in the critical premises of fairness and transparency to applicants, though legal protection of counselor education programs is also enhanced by using clear, standardized processes. Dispositional assessment is in its infancy, especially when applied to counselor education in general and to program admissions in particular. How exactly to define dispositions as well as how exactly the role of the counselor will serve as a means of selection and gatekeeping for the profession is yet to be determined. Yet counselor educators perceive both an ethical and professional responsibility for monitoring counseling student dispositions as a means for safeguarding the integrity of the profession (Freeman et al., 2019; Schuermann et al., 2018). The continued development of the PDCA-R and the PDCA-RA, as well as the associated training materials, represents initial steps toward standardizing and improving dispositional appraisal. The video-based training and the exploration of the training as a means of improving rater consistency will potentially increase the ability of counselor educators to consistently assess and monitor developing counseling students. Consistent dispositional ratings can also contribute to the development of a common language for discussing student progress. The current research represents a promising effort to continually improve the dispositions assessment process for counselor educators, counseling programs, and the counseling profession.
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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Curtis Garner, EdD, NCC, NCSC, LCPC, is a professor and department chair at Gonzaga University. Brenda Freeman, PhD, is a professor at the University of Nevada, Reno. Roger Stewart, PhD, is a professor at Boise State University. Ken Coll, PhD, is the Dean of the School of Education at the University of Nevada, Reno. Correspondence may be addressed to Curtis Garner, 502 East Boone Ave., Spokane, WA 99258-0102, firstname.lastname@example.org.
Tyler Wilkinson, Rob Reinhardt
The use of technology in counseling is expanding. Ethical use of technology in counseling practice is now a stand-alone section in the 2014 American Counseling Association Code of Ethics. The Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act provide a framework for best practices that counselor educators can utilize when incorporating the use of technology into counselor education programs. This article discusses recommended guidelines, standards, and regulations of HIPAA and HITECH that can provide a framework through which counselor educators can work to design policies and procedures to guide the ethical use of technology in programs that prepare and train future counselors.
Keywords: counselor education, technology, best practice, HIPAA, HITECH
The enactment of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) brought forth a variety of standards addressing the privacy, security and transaction of individual protected health information (PHI; Wheeler & Bertram, 2012). According to the language of HIPAA (2013, §160.103), PHI is defined as “individually identifiable health information” (p. 983) that is transmitted by or maintained in electronic media or any other medium, with the exception of educational or employment records. “Individually identifiable health information” is specified as follows:
Information, including demographic data, that relates to:
- the individual’s past, present or future physical or mental health or condition,
- the provision of health care to the individual, or
- the past, present, or future payment for the provision of health care to the individual, and that identifies the individual for which there is a reasonable basis to believe can be used to identify the individual. Individually identifiable health information includes many common identifiers. (U.S. Department of Health and Human Services [HHS], n.d.-b, p. 4)
The HIPAA standards identify 18 different elements that are considered to be part of one’s PHI. These include basic demographic data such as names, street addresses, elements of dates (e.g., birth dates, admission dates, discharge dates) and phone numbers. It also includes information such as vehicle identifiers, Internet protocol address numbers, biometric identifiers and photographic images (HIPAA, 2013, § 164.514, b.2.i).
According to language in HIPAA, the applicability of its standards, requirements and implementation only apply to “covered entities,” which are “(1) a health plan (2) a health care clearinghouse (3) a health care provider who transmits any health information in electronic form in connection with [HIPAA standards and policies]” (HIPAA, 2013, § 160.102). Covered entities have an array of required and suggested privacy and security measures that they must take into consideration in order to protect individuals’ PHI; failure to protect individuals’ information could result in serious fines. For example, one recent ruling found a university medical training clinic to be in violation of HIPAA statutes when network firewall protection had been disabled. The oversight resulted in a $400,000 penalty (Yu, 2013). Moreover, the recent implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 increased the fines resulting from failure to comply with HIPAA, including fines for individuals claiming they “did not know” that can range from $100–$50,000 (Modifications to the HIPAA Privacy, 2013, p. 5583). The final omnibus ruling of HIPAA–HITECH, enforcing these violations, went into effect on March 26, 2013 (Modifications to the HIPAA Privacy, 2013; Ostrowski, 2014). Enforcement of the changes from the HITECH Act on HIPAA standards began on September 23, 2013, for covered entities (Modifications to the HIPAA Privacy, 2013).
Academic departments and universities must understand the importance of HIPAA and HITECH regulations in order to determine whether the department or university is considered a covered entity. Risk analysis and management need to be employed to avoid violations leading to penalties and fines (HIPAA, 2013, §164.308). Some counselor education programs that have students at medically related practicum or internship sites also may be considered business associates (see HIPAA, 2013, § 160.103) and would need to comply with HIPAA regulations (see HIPAA, 2013, § 160.105). The authors recommend that all counselor education programs confer with appropriate legal sources to understand any risks or liabilities related to HIPAA regulations and relationships with practicum and internship sites. Many states also have their own unique privacy laws that must be considered in addition to those described in HIPAA regulations. The purpose of this article assumes that a counselor education department is not considered a covered entity by the regulations set forth by HIPAA. However, as an increasing number of counselor education programs incorporate the use of digital videos or digital audio recordings, a need for a set of policies and procedures to guide the appropriate use of digital media is evident.
The authors believe that the regulations set forth by HIPAA and HITECH create a series of guidelines that could dictate best practices for counselor educators when considering how to utilize technology in the collection, storage and transmission of any individual’s electronic PHI (Wheeler & Bertram, 2012) within counselor education programs. HIPAA regulations (2013, §160.103) describe electronic protected health information (ePHI) as any information classified as PHI, as described above, either “maintained by” or “transmitted in” (p. 983) electronic media. For example, audio recordings used in practicum and internship courses are often collected electronically by digital recorders. If the recordings remain on the device, this protected information is being maintained in an electronic format. If the data is shared through e-mail or uploaded to a computer, then it is being transmitted in electronic format. As it relates to counselor training, the PHI that is collected could be real or fictitious (i.e., from someone role playing in the program). Though fictitious information is not necessarily protected, encouraging students to engage in implementing a set of policies and procedures guided by regulations of HIPAA and HITECH creates an experiential milieu whereby students become aware of and learn the importance of security and privacy when handling digital ePHI. The authors will discuss throughout this article how specific regulations from HIPAA and HITECH can be utilized to create a set of policies and procedures that guide the ways in which members of counselor education programs can handle any ePHI they encounter during their training. These direct experiences will give faculty and students greater familiarity with current HIPAA and HITECH regulations, thus making them better prepared to work ethically and legally in modern mental health culture.
This article is not meant to cover HIPAA and HITECH regulations in a comprehensive manner. Overviews of these standards have been written concerning the regulations of HIPAA and HITECH regarding the work of mental health practitioners (see Letzring & Snow, 2011). The degree to which the myriad regulations of HIPAA will be implemented in various counselor education programs will need to be decided by the members of individual programs and by necessary stakeholders. The authors hope to introduce a dialogue regarding the thoughtful use of technology in counselor education programs guided by the parameters set forth by HIPAA.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA; 2013), the trend in mental health care treatment spending is in the direction of public (i.e., Medicare and Medicaid) and private insurance growth as a means of payment. Spending for all mental health and substance abuse services totaled $172 billion in 2009; moreover, this spending accounted for 7.4% of all health care spending that year. Additionally, it is projected that spending on all mental health and substance abuse services could reach $238 billion by 2020 (SAMHSA, 2014). However, the rate at which individuals pay out-of-pocket for mental health and substance abuse services is expected to decrease steadily (SAMHSA, 2014). Historical trends show out-of-pocket spending decreased from 18% of all spending in 1986 to 11% in 2009 (SAMHSA, 2013, 2014). It is projected that out-of-pocket spending for mental health treatment will level off to account for approximately 10% of all spending while Medicaid, Medicare, and private insurance will account for approximately 70% of spending (SAMHSA, 2014). The trend toward greater insurance use will increase the number of professional counselors who will be seen as or will be working within organizations that are considered HIPAA-covered entities. Implementing policies and procedures in counseling departments that incorporate some of the HIPAA regulations is a useful way to prepare future professionals for the working environment they will enter (SAMHSA, 2013).
The implementation of the HITECH Act (2009) as a supplement to HIPAA emphasized the need to make sure future counselors understand the importance of the increasing role of technology in the practice of counseling (Lawley, 2012). The HITECH Act established an expectation that professionals in health care must be familiar with technology, specifically as it relates to policies guiding the storage and transmission of ePHI. The objectives of HITECH include “the electronic exchange and use of health information and the enterprise integration of such information” and “the utilization of an electronic health record for each person in the United States by 2014” (HITECH, 2009, §3001.c.A, emphasis added). Additionally, HITECH strengthened the enforcement of penalties for those who violate HIPAA (Modifications to the HIPAA Privacy, 2013). A multi-tiered system of violations allows for civil money penalties to range from $100–$50,000 per violation (Modifications to the HIPAA Privacy, 2013). The American Counseling Association’s (ACA) 2014 Code of Ethics acknowledged the increasing use of technology by professional counselors by introducing a new section (Section H) addressing the ethical responsibility of counselors to understand proper laws, statutes, and uses of technology and digital media. Ethical counselors are expected to understand the laws and statutes (H.1.b), the uniqueness of confidentiality (H.2.b), and the proper use of security (H.2.d) regarding the use of technology and digital media in their counseling practice.
The mental health care system exists inside the broader health care system. As such, graduates of counseling programs must be familiar with HIPAA regulations and the various modes of technology to implement these regulations (ACA, 2014; Lawley, 2012). Students will be expected to understand what security and privacy standards are required of them once they begin working as counseling professionals (ACA, 2014). For example, the movement toward increased use of ePHI across health care will place increasing demands on students to understand how to appropriately keep electronic data private and secure. Counselor educators need to be mindful of how the use of technology in the practice of counseling is being taught and implemented with counseling students. Counselor educators should thoughtfully consider how students will learn the ways in which technology can be used professionally while maintaining ethical and legal integrity (Association for Counselor Education and Supervision [ACES] Technology Interest Network, 2007; Wheeler & Bertram, 2012). Having standards to guide the use of ePHI throughout counselor education programs is a way in which students can become knowledgeable and skilled regarding the laws and ethics surrounding digital media. Policies and procedures should include information guiding the ways in which students collect, store and transmit digital media (e.g., audio recordings or videotapes) while a member of the counseling program. By requiring students to utilize the ePHI (real or fictitious) they collect in accordance with policies and procedures informed by HIPAA and HITECH, students crystallize their understanding of these complicated laws.
HIPAA Compliance and Technology
Complying with HIPAA Privacy and Security Rules requires individuals to be mindful of policies and procedures, known as “administrative safeguards” (HIPAA, 2013, §164.308, p. 1029), and work to implement safeguards consistently. The HHS has made clear that it does not provide any type of credential to certify that an individual, business, software or device is HIPAA compliant (HHS, n.d.-a; Reinhardt, 2013). Complying with HIPAA rules requires organizations and individuals to address many different processes where choice of hardware or software is only one aspect (Christiansen, 2000). Being HIPAA compliant is less about a certification or a credential on a device and more about having a set of policies and procedures in place that ensure the integrity, availability and confidentiality of clients’ ePHI (Christiansen, 2000; HHS, n.d.-b). Hardware and software technology companies who make claims that a product or an educational resource is HIPAA compliant are likely doing so for marketing purposes. Claims of this type are mostly meaningless (HHS, n.d.-a) and would not provide protection in the case of a breach (HITECH, 2009). Being HIPAA compliant is an “organizational obligation not a technical specification” (Christiansen, 2000, p. 7). The distinction is important for educators to understand as they seek to implement technology in counselor education programs. When establishing a set of policies and procedures within a counseling department, the recommendations set forth in describing the security and privacy of PHI in Part 164 of HIPAA (2013) can be an appropriate framework for establishing best practices for counselors and counselor educators. The general requirements in complying with HIPAA security standards are to ensure the confidentiality, integrity and availability of individuals’ ePHI while protecting against any reasonably anticipated threats to the security and privacy of said ePHI (HIPAA, 2013, §164.306.a). The key phrase to consider is that covered entities are asked to protect against any “reasonably anticipated” (HIPAA, 2013, §164.306.a, p.1028) threat. Educators must understand the importance of spending time considering reasonable, foreseeable risks. A primary responsibility is to create administrative safeguards that address any reasonable, foreseeable risks, which the individual, department or covered entity establishes.
Before looking at key aspects of HIPAA Privacy and Security guidelines, key definitions should be understood:
- Administrative safeguards include policies and procedures used to manage the development, selection, implementation and security in protecting individuals’ ePHI (HIPAA, 2013, § 164.304).
- Authentication includes “the corroboration that a person is the one claimed” (HIPAA, 2013, § 164.304, p. 1027).
- Confidentiality defines “the property that data or information is not made available or disclosed to unauthorized persons or processes” (HIPAA, 2013, § 164.304, p. 1027).
- Encryption is “the use of an algorithmic process to transform data into a form in which there is a low probability of assigning meaning without the use of a confidential process or key” (HIPAA, 2013, § 164.304, p. 1027).
- Security incident is described as “the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operation in an information system” (HIPAA, 2013, § 164.304, p. 1027).
HIPAA (2013) standards are categorized as either required or addressable as indicated in Section 164.306.d.1. The rest of this document will highlight the standards that the authors believe shape a set of best practices for counselor educators when implementing technology into their counselor education programs. The degree to which a counseling program decides to implement those standards that are considered required or addressable will be determined by their status as a covered entity, state laws, needs of their counseling program and the financial feasibility of implementing these standards.
HIPAA requires that all covered entities maintain policies and procedures that (1) ensure confidentiality and availability of all electronic PHI, (2) protect against any reasonably (emphasis added) anticipated threats or hazards to the security or integrity of ePHI, (3) protect against any reasonably anticipated uses or disclosures of ePHI, and (4) ensure compliance by the workforce. The following sections will discuss ways in which HIPAA Privacy and Security rules can be utilized as best practices in counselor education programs so that foreseeable risks, threats and vulnerabilities may be minimized. Please note that this interpretation of safeguards is intended for the consideration of counselor education programs that are not covered entities, but may use HIPAA Privacy and Security rules to establish a set of policies and procedures as a means of best practice. (For a sample guide for counselor educators to use in developing policies and procedures, please contact the first author).
Administrative actions and oversight make up an important component of the language within HIPAA (2013). Administrative safeguards consist of the policies and procedures designed to “manage the selection, development, [and] implementation” (§ 164.304, p. 1027) of the security and privacy of one’s ePHI. This section describes HIPAA standards to consider when establishing administrative safeguards.
Assigned responsibility. A faculty or staff member within the counselor education program should be identified as responsible for the development, oversight and implementation of the policies and procedures for the department. The faculty member needs to be familiar with the privacy and security policies of HIPAA in order to implement the policies and procedures and to facilitate student training in ways that address the specific needs of the program. Developing a relationship with a staff member in the university information technology department may result in collaborative efforts regarding specific procedures for the use of technology within the university.
Risk analysis. Before counselor educators can design a set of policies and procedures to guide appropriate technology use, the foreseeable risks must be analyzed. An accurate and thorough assessment is needed to identify potential risks to the protection and security of ePHI (HIPAA, 2013, §164.308) that is collected, stored and transmitted in the counseling program. Analyzing potential risk is essential to the minimization of potential disasters in the future (Dooling, 2013). HHS (2007) makes clear that it is important to spend time considering reasonably anticipated threats and vulnerabilities and then to implement policies and procedures to address the assessed risks. HIPAA security standards do not state that covered entities should protect against all possibly conceived threats, but those that can be “reasonably anticipated” based upon the technologies employed, work environments and employees of the covered entity. The National Institute of Standards and Technology (NIST; 2012) defines a threat “as any circumstance or event . . . with the potential to adversely impact organization operations . . . through an information system via unauthorized access, destruction, disclosure, or modification of information” (p. B-13). A risk is a measure of the probability of a threat triggering a vulnerability in the procedures that an organization uses to ensure the privacy and security of ePHI (NIST, 2012). Vulnerabilities are technical and non-technical weaknesses, which include limitations in utilized technology or ineffective policies within the organization (HHS, 2007). In counselor education programs, risk analysis may include looking at the threats and vulnerabilities associated with counseling students traveling between their residence, campus, and practicum or internship sites while carrying ePHI. Moreover, the analysis must include assessing the potential risks associated with the transmission and storage of protected information using technological media (e.g., e-mail, personal computers, cloud-based storage, external storage devices).
Risk management. Risk management is the ongoing process of implementing measures to reduce the threats that were determined as a part of the risk analysis (HHS, 2007). Once a counseling program has assessed and identified potential risks associated with the collection, transmission and storage of any identifiable information, it must begin to manage these risks. HHS has provided an example list of steps to assist organizations in conducting risk analysis and risk management (see Table 1). Members of counselor education programs can begin to incorporate programmatic policies and procedures that address how media containing ePHI should be handled by members of the program. The previously mentioned document (available from the first author) provides sample policies and procedures developed to serve as a guide for counseling programs. Many counselor education programs utilize student handbooks that detail policies related to the academic and professional expectations of students enrolled in their program. Incorporating an additional set of policies to address the treatment of ePHI is a seamless way to begin managing the risks of technology use in mental health. By implementing policies and procedures across the curriculum, students become increasingly knowledgeable and skilled at handling ePHI in an ethical manner.
Example Risk Analysis and Risk Management Steps
||Identify the scope of the analysis.
||Identify and document potential threats and vulnerabilities.
||Assess current security measures.
||Determine likelihood of threat occurring.
||Determine potential impact of threat occurrence.
||Determine level of risk.
||Identify security measures and finalize documentation.
||Develop and implement a risk management plan.
||Implement security measures.
||Evaluate and maintain security measures.
Note. Adapted from “Basics of Risk Analysis and Risk Assessment,” by the U.S.
Department of Health and Human Services, 2007, HIPAA Security Series, 2(6), p. 5.
Sanction policy. It must be communicated to all members of counselor education programs that failure to comply with the policies will result in sanctions. HIPAA (§164.308, 2013) requires organizations to enforce sanctions against individual members for failing to comply with their organization’s policies and procedures. A counselor education program should have clearly documented policies and procedures for students and staff involved with the facilitation of ePHI. The language of HIPAA makes no attempt to clarify as to what these sanctions should entail; however, language needs to exist that addresses individuals’ failure to comply. For counseling students, a potential option is to consider a tiered sanction policy similar to that of the structure established by the HITECH Act (Modifications to the HIPAA Privacy, 2013) and § 1176 of the Social Security Act (2013). Varying categories of violations from “did not know” (p. 5583) to uncorrected–willful neglect result in increasingly severe fines (Modifications to the HIPAA Privacy, 2013). Since this experience is most likely educational for students, varying degrees of failure to comply could exist. For counselor education programs, this language also could easily be tied to student remediation processes that many counseling programs utilize.
Information review. Ongoing review of the activity of students, faculty and staff that involves the creation, storage and transmission of ePHI is a required safeguard according to HIPAA standards (2013, §164.308). As an educational unit, it is understandable that individuals might make mistakes regarding the implementation of HIPAA safeguards. A regular review of the activity and records of the individuals whose ePHI are being collected is important. It is required for organizations to have policies in place for recording system activity, including access logs and incident reports (§ 164.308). Additionally, protections must be in place to ensure that only those individuals who should have access to any ePHI are able to access this protected information. In the case of the sanctioned university medical training clinic cited earlier, the breaches might have been avoided with an ongoing review of the system’s firewall settings (Yu, 2013). Monitoring and developing policies regarding information review may require developing relationships and discussions with the appropriate information technology personnel at the organization.
Response, recovery and reporting plan. HIPAA regulations require that a covered entity have a plan in place should ePHI be breached or disclosed to an unauthorized party (HIPAA, 2013, § 164.308). When developing departmental policies and procedures, it is important to have such a plan in place. Whether the breach or disclosure is intentional or unintentional, each individual whose information has potentially been compromised needs to be notified. Moreover, in cases where more than 500 individuals’ PHI have been breached, the entity may need to report this information to local media or to HHS (HIPAA, 2013, §164.406–164.408). It should be noted that covered entities could be exempted from breach notification through employing security techniques such as encryption (Breach Notification, 2009; HIPAA, 2013, §164.314). The regulations of HIPAA require that a plan be in place to address emergencies (HIPAA, 2013, §164.308). In the case of theft, emergency or disaster, counseling departments need a data backup and recovery plan in place to retrieve ePHI.
Establishing policies and procedures that protect against unauthorized physical access and damage from natural or environmental hazards is critical to maintaining the security and privacy of PHI (HIPAA, 2013, §164.310).
Access control. When using technology to store and transmit ePHI, the recommendation is that policies address ways in which physical access to protected information will be limited. For example, many counseling departments now incorporate the use of digitally recorded data from counseling sessions (e.g., audio or video). Policies need to clearly address how to best limit physical access to these recordings. Students need to understand what it means to keep data physically secure. The HITECH Act (Modifications to the HIPAA Privacy, 2013) includes the category “did not know” as a punishable violation. Students need to understand the consequences of failing to implement such physical safeguards. For example, keeping devices stored under lock and key when not in use is just one important step in moving toward a set of best practices. Many universities already require students to utilize login information with a username and passcode in order to access computers affiliated with their respective university. Consideration may need to be given regarding policies and procedures for accessing ePHI off campus, where the technical security may be less controlled.
Disposal and re-use. HIPAA requires covered entities to implement policies that address the disposal and re-use of ePHI on electronic media. A detailed discussion of the various types of disposal, also known as media sanitization, and re-use is beyond the scope of this article (see Kissel, Regenscheid, Scholl, & Stine, 2014). Counselor education programs must recognize the importance of properly removing protected information from media devices after it is no longer required. Media sanitization is a critical element in assuring confidentiality of information (Kissel et al., 2014). For example, in counseling internship courses, students may be asked to delete recorded sessions during the last day of classes so that the instructor can have evidence of the appropriate disposal of this information. NIST identifies four different types of media sanitization: disposal, clearing, purging and destroying (Kissel et al., 2014). The decision as to which type of media sanitization is appropriate requires a cost/benefit analysis, as well as an understanding of the available means to conduct each type of sanitization. (The authors recommend counseling departments consult with an individual from the university information technology department).
The language in HIPAA is clear regarding the implementation of technical safeguards, requiring that access to electronic media devices containing PHI be granted only to those who need such access to perform their duties.
Unique user identification. If a device allows for unique user identification, one should be assigned to minimize the unintended access of ePHI. HIPAA standards (2013, §164.514) state that an assigned code should not be “derived from or related to information about the individual” (p. 1064).
Emergency access. Covered entities are required to have procedures in place that allow ePHI to be accessed in the event of an emergency (HIPAA, 2013, §164.310). The procedures can be addressed within counselor education programs so as to ensure that the student and the supervisor have access to the ePHI at the designated storage location.
Encryption. Encryption is a digital means of increasing the security of electronic data. Using an algorithmic process, the data is scrambled so that the probability of interpretation is minimal without the use of a confidential key to decode the information. Though the language of HIPAA categorizes encryption as addressable rather than required, the implementation of encryption policies is a best practice to help ensure the protection of ePHI. The language of HIPAA makes it clear that an “addressable” item must be implemented if it is “reasonable and appropriate” (HIPAA, 2013, §164.306, p. 1028) to do so. Huggins (2013) has recommended that ePHI be stored on drives that allow for “full disk encryption” at a minimum strength of 128 bits. With the availability of many different types of software packages that can encrypt at a recommended strength, implementing encryption standards in a counseling department is affordable and reasonable. Most modern computer operating systems have options to encrypt various drives built into the functionality of the system. Full disk encryption is recommended because of its higher level of security and also because it can provide exemption from the Breach Notification Rule mentioned earlier (Breach Notification, 2009). In case of a breach, the burden is on the covered entity to prove that the ePHI was not accessed; otherwise, Breach Notification Rules must be followed. The assumption is that if a disk is fully encrypted, even if accessed by an unauthorized person, it is highly unlikely that an unauthorized party will obtain access to the ePHI (Breach Notification, 2009). The authors strongly encourage the use of encrypted devices as a standard policy for the collection and storage of ePHI (see Scarfone, Souppaya, & Sexton, 2007). The policy creates greater protection against the accidental disclosure of an individual’s ePHI. Additionally, organizations that use commercial cloud storage service providers should investigate whether these providers are willing to sign a Business Associate Agreement, in which the provider agrees to adhere to regulations of HIPAA (2013, §160.103). If not, the storage of ePHI may not be in alignment with HIPAA standards.
Disk encryption works well for the storage and collection of protected information while at rest (Scarfone et al., 2007); however, counselor education programs also should consider assessing the risk associated with the transmission of ePHI (HIPAA, 2013, §164.312). Protected information often remains encrypted while at rest, yet becomes unencrypted while in transmission. Programs need to “guard against unauthorized access to electronic PHI that is being transmitted over an electronic communication network” (HIPAA, 2013, §164.312, p. 1032). Commonly used e-mail systems, for example, often do not transmit information in an encrypted state. Assessment of the risks in sending protected information by an unsecured means should be conducted.
The language of HIPAA allows each covered entity some leeway in how it wants to implement policies. However, HIPAA standards (2013, §164.316) are very clear that entities should “implement reasonable and appropriate policies”(p. 1033) that include administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of electronic PHI that it creates, receives, maintains or transmits. The implementation of HITECH (2009) and the meaningful use policies of the Affordable Care Act (Medicare and Medicaid Programs, 2014) emphasized the movement of the broader health care system toward increasing use of health care technology such as Electronic Health Records. Students graduating from counseling programs find themselves working in myriad settings, many of which are considered covered entities as defined in the HIPAA standards (2013, §160.103). It is imperative for counselor educators to recognize the trend toward increased technology use in the health care market and to consider ways that technology can be infused into counselor education so that students are entering the workforce with greater technological competence. Specifically, counselor educators have an imperative to teach the ethical and legal technological mandates that exist as they relate to regulations of HIPAA (2013) and HITECH (2009) so as to create competent counselors. As the health care industry continues to incorporate more technology, counselor educators must stay informed regarding ways in which graduates will utilize this technology in their professional careers.
Recommendations for Counselor Educators
ACES (2007) published a document that recommends guidelines for infusing technology into counselor education curriculum, research and evaluation. This document provides a basic overview by which programs should guide the very broad use of technology in counseling programs. Technology is presented as a useful enhancement or supplement to practice. The shift in the broader health care culture has moved technology from a supplementary role into one in which it is primary to the ongoing success of a practitioner. The authors believe that counselor educators can utilize HIPAA and HITECH regulations to continue to infuse technology into counselor education programs, and recommend the following:
- Counselor educators need to increase the importance placed on technology in counselor education programs. The movement of technology into increasingly primary roles in health care is indicative of the need for it to become a primary focus during the education and training of counselors. Counselors and counselor educators must stay abreast of the trends and developments regarding health care law and technology. The implementation of Section H, “Distance Counseling, Technology, and Social Media,” in the 2014 ACA Code of Ethics also is indicative of this need. The counseling profession needs to increase the research, education and training available to counselors and counselor educators.
- Counselor educators need to have policies and procedures in place guiding the use of technology in their departments. The overview of HIPAA regulations will help provide guidelines for developing a set of policies and procedures. All policies and procedures must be in writing and accessible to students, faculty and staff who have access to any ePHI. Many counseling programs maintain a student handbook in which a set of standards that dictate the use of technology could easily be incorporated. Departmental policies should be in place that dictate the consequences should an individual fail to adhere to the stated policies and procedures.
- Counselor educators should be actively seeking ways in which technology and HIPAA can be incorporated to best prepare students for their future work environment. The regulations and language of HIPAA and HITECH should be addressed in course activities. Are counseling students getting opportunities to become familiar with Electronic Health Records? Are students having opportunities to write and store notes electronically? Have students addressed the ethical and legal concerns related to the use of technology in practice? Do students understand what it means to maintain encrypted files or how to appropriately de-identify ePHI? Do students understand how to submit health insurance claims electronically? Questions like these are necessary for students to understand so they can be prepared to work in the current mental health environment as competent professionals.
The use of technology in counseling is moving from a secondary to a primary place in counselor education. The expectation that students can find this information after graduation in the form of a workshop is no longer acceptable. The shifts in the language of HIPAA and HITECH have moved the broad health care field in an electronic, digital direction. The familiarity with technology seems to be growing toward a core competency of counselor education programs and faculty. The laws dictated by HIPAA and HITECH provide a framework by which counselor educators can continue to infuse technology into the classroom and clinical experiences.
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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Tyler Wilkinson, NCC, is an Assistant Professor at Mercer University. Rob Reinhardt, NCC, is in private practice in Fuquay-Varina, NC. Correspondence may be addressed to Tyler Wilkinson, 3001 Mercer University Drive, AACC 475, Atlanta, GA 30341, Wilkinson_rt@mercer.edu.
Carl Sheperis, Donna Sheperis, Alex Monceaux, R. J. Davis, Belinda Lopez
Parent–Child Interaction Therapy (PCIT) is an evidence-based method for reducing disruptive behavior in children and improving parent management of behavior. PCIT is a form of behavioral intervention that can be used in clinical, home and school settings. Although initially designed for intervention related to oppositional defiant disorder and conduct disorder, PCIT has been found to be a promising intervention for addressing behavioral issues among children with special needs. We present methods, research-based instructions and a case example of PCIT with a child diagnosed with autism. This article is intended to assist professional counselors in designing appropriate interventions for both children and parents.
Keywords: autism, parent–child interaction therapy, special needs, behavioral intervention, case example
Counseling techniques for children stem from a myriad of theoretical perspectives, and professional counselors are often in the unique position to provide systems intervention and training to families when a child has disruptive behavior. Despite the seniority of behaviorism in the field of psychology, behavioral family approaches have only recently been acknowledged as an effective practice in professional counseling. According to Gladding (2011), the following three premises underlie behavioral family counseling: (a) all behaviors are learned, (b) maladaptive behaviors are the target for change and (c) not everyone in the family has to be treated for change to occur. With these assumptions, it is easily deduced that the following also are true: (a) behavior can be unlearned and that new behaviors can be taught, (b) underlying, unresolved issues are not the key components of treatment, and (c) positive changes for one family member will impact the entire family system and surrounding ecology.
When working with children of preschool or early elementary age, it is important to directly involve the child’s caregivers. Parents’ influence on their children is significant and some parenting practices may exacerbate some children’s problems (McNeil & Hembree-Kigin, 2010). Behavioral family counseling models recognize the relationship between the child’s behavior and the family system. One behavioral family counseling technique, Parent-Child Interaction Therapy (PCIT), helps families work together with their children in reaching therapeutic goals. PCIT involves teaching parents some fundamental relationship-building strategies, including therapeutic play techniques for parents to use in the home environment (Johnson, Franklin, Hall, & Prieto, 2000). The clinician typically teaches and models PCIT techniques for the parents over the course of 8–10 weeks.
The purpose of this article is to demonstrate the practicality of PCIT as a component of behavioral family counseling, to facilitate the professional counselor’s understanding of the model through a review of PCIT and to illustrate the utility of this model for children with special needs through a case study.
An Overview of PCIT
PCIT (Neary & Eyberg, 2002) is an assessment-driven form of behavioral parent training designed for families with preschool-aged children. We present a brief overview of PCIT, define the key components integral to the process, provide the framework for implementation and discuss the application of PCIT to special populations. The core of PCIT is twofold—to create nurturing parent–child relationships and to model prosocial behaviors while increasing a child’s appropriate, compliant behaviors (Eyberg & Boggs, 1989). Play therapy skills are introduced to parents within the PCIT model to enhance the relationship between the parent and child. Additionally, PCIT cultivates problem-solving skills with parents who can then generalize gains made in the therapeutic milieu into the family environment. Similar to other models of family counseling, PCIT begins with the assessment process. Counselors using PCIT collect psychosocial information from the family through either structured or semistructured clinical interviews. Because PCIT is a behavioral model, family dynamics also are assessed through direct observation of clients. Once clinical interview and observational data are collected and evaluated, the counselor can explore family relationship dynamics.
PCIT counselors attempt to identify family roles, interactions and maladaptive disciplinary techniques (e.g., yelling, lack of follow-through, unrelated consequences) inherent in the system. The ultimate goal of these observations is to derive methods for replacing current ineffective parenting strategies with more adaptive ones, thus creating greater stability in the family system. Similar to other parenting approaches, family counselors using PCIT offer support and assistance in improving parent–child relationships without placing blame on the child or the parents (Webster-Stratton & Herbert, 1993).
The Benefits of PCIT
There are many benefits to PCIT; it is a brief, short-term family counseling procedure that teaches effective parenting skills and helps parents interact better with their children on a daily basis. Fundamentally, PCIT’s two-tailed approach benefits both parents and children (Asawa, Hansen, & Flood, 2008) by reducing the internalization of problems and parent–child stress. Additionally, PCIT empowers parents through teaching positive interactive techniques that build parent–child rapport. PCIT fosters creativity and increases child self-esteem, decreases noncompliance or disruptive behavior, and increases the quality of parent-provided positive regard through developmentally appropriate play (Eyberg et al., 2001). These positive interactions effectively decrease problem behavior, resulting in a reduction or elimination of emergency counseling visits. One PCIT study reported that only 19% of participants in a randomized controlled trial with physically abusive parents re-reported physical abuse more than 2 years after the implementation of the PCIT model (Chaffin et al., 2004).
While PCIT sessions may focus on home and play, the behavioral skills that the parent learns can be generalized to other children and additional settings, building stronger interactions across a spectrum of familial and social settings. According to Urquiza and Timmer (2012), PCIT focuses on the following three essential non-fixed elements: (a) increased positive parent–child interaction and emotional communication skills, (b) appropriate and consistent discipline methods, and (c) direct scaffolding for parent training in the interventions. Thus, once the parent has mastered these skills in the session with the child and therapist, the parent is able to transfer the skills to any location or setting to maintain positive interactions, emotional communication and disciplinary consistency with the child.
The Effectiveness of PCIT
Eyberg and her colleagues have researched and published extensively on the efficacy of PCIT and have empirically supported the effectiveness of PCIT with children exhibiting a range of behavioral and emotional problems (Neary & Eyberg, 2002). Specifically, PCIT has proven effective with problems including attention-deficit/hyperactivity disorder (ADHD), conduct disorders, separation anxiety, depression, postdivorce adjustment, self-injurious behavior and abuse (Eyberg et al., 2001; McNeil & Hembree-Kigin, 2010). For example, Nieter, Thornberry, and Brestan-Knight (2013) conducted a pilot study with 17 families completing PCIT treatment and found a significant decrease in disruptive child behaviors as well as a decrease in inappropriate parent behaviors over the 12-week group program. This study was the first to deliver PCIT via group sessions. The researchers found that treatment effects remained in place for more than 6 months after the group’s completion.
Eyberg et al. (2001) investigated long-term treatment outcomes of PCIT for families of preschoolers with conduct disorders over a period of 1–2 years, and found that treatment effects were sustained over time. According to the researchers, the study was the first of its kind to include long-term follow-up with families receiving PCIT treatment (Eyberg et al., 2001). Hood and Eyberg (2003) established further evidence in another follow-up study on PCIT treatment effects over a period of 3–6 years. In the study of treatment effects on families with young children diagnosed with oppositional defiant disorder, the researchers found that treatment effects and behavioral change were again sustained over time. Thomas and Zimmer-Gembeck (2007) conducted a review of behavior outcomes in 24 studies on PCIT and another parenting intervention, Triple P—Positive Parenting Programs. All of the studies involved children aged 3–12 and their caregivers. Meta-analyses revealed positive effects for PCIT as well as the other intervention, adding support within the literature on the efficacy of PCIT.
To demonstrate the effectiveness of PCIT for treating ADHD, Guttmann-Steinmetz, Crowell, Doron, and Mikulincer (2011) examined the interactions of children with ADHD and their mothers. Their findings suggest that while Behavior Parent Training is useful in managing ADHD, PCIT may be highly effective in impacting the attachment-related processes during the child’s later developmental stages. These researchers suggested that parents’ successful adaptation of PCIT’s verbal and behavioral skills during interaction with their child might increase the child’s sense of security.
The effectiveness of PCIT has been expanded to other disorders such as separation anxiety. For example, Choate, Pincus, Eyberg, and Barlow (2005) conducted a pilot study involving three families with children 4–8 years of age diagnosed with separation anxiety disorder. The researchers found that the child-directed activities fostered children’s sense of control and reduced separation anxiety symptomology to normative levels by the conclusion of treatment. Again, the treatment effects were shown to persist long after treatment ceased. This study was replicated by Anticich, Barrett, Gillies, and Silverman (2012), providing further support of PCIT’s effectiveness in alleviation of separation anxiety disorder symptomology.
Individuals or populations with special needs also appear to respond positively to PCIT. Bagner and Eyberg (2007) found that mothers of young children diagnosed with mental retardation and oppositional defiant disorder reported a reduction in disruptive behaviors, increased compliance and less parenting stress after participating in a randomized, controlled trial study utilizing PCIT. PCIT also has been cited as a promising evidence-based intervention for autism (Agazzi, Tan, & Tan, 2013). Solomon, Ono, Timmer, and Goodlin-Jones (2008) conducted a randomized trial of PCIT for treating autism and found the same results as researchers studying other disorders have. PCIT was shown to reduce behavioral disruptions, increase adaptability and increase positive parental perceptions of child behavior. While PCIT was originally developed to address behavioral disorders, it clearly serves as an intervention for various other disorders that impact parent–child interactions.
The impact of PCIT on parents. PCIT has been shown to have equally effective outcomes for parent-related issues as it does for child behavioral disruptions. For example, Luby, Lenze, and Tillman (2012) reported highly favorable results for using PCIT to reduce behavioral disruptions and improve executive function among preschoolers. However, PCIT also showed significant effects for parents. Specifically, PCIT interventions helped to reduce depression severity and parenting stress while increasing emotion recognition. Furthermore, Urquiza and Timmer (2012) found that parental depression decreases the likelihood that the child will complete the treatment course. However, if the parents are persuaded to continue until completion, their own psychological symptoms may be relieved.
PCIT has been shown to have positive effects on parents in a variety of circumstances. For example, Baker and Andre (2008) suggested that PCIT might offer a unique and promising advantage in the treatment of postdivorce adjustment issues in children. PCIT also has been found to be effective in working with abusive parents, many of whose histories included depression, substance abuse and violent behavior (Chaffin et al., 2004). Although still effective in reducing parenting stress and child behavior problems, Timmer et al. (2011) found that PCIT was less effective in foster parent homes than in non-foster parent homes. While PCIT is clearly an effective intervention for both children and parents, in cases with complex systems like foster care placement and abuse, PCIT could be used in conjunction with other interventions. The same is true for clients with special needs.
Diverse population efficacy. Although we recognize that one size does not fit all, PCIT has shown significant results with ethnic minorities and underserved populations. Different cultural and ethnic group parenting styles (strict vs. relaxed styles) vary across the United States. In addition to effectively increasing positive parenting behaviors and deceasing behavioral problems in children, treatment outcomes and efficacy studies support the notion that PCIT is culturally effective and produces robust modifications among diverse groups (see Bagner & Eyberg, 2007; Borrego, Anhalt, Terao, Vargas, & Urquiza, 2006; Matos, Torres, Santiago, Jurado, & Rodríguez, 2006; McCabe & Yeh, 2009). Additional literature and empirical research is available for review regarding work with specific populations such as African Americans and Asians. There also is promising evidence pointing to PCIT’s efficacy in populations exhibiting neurological and behavioral disorders such as autism (Tarbox et al., 2009).
Efficacy through translation. Matos et al. (2006) conducted research in Puerto Rico with parents of children aged 4–6 with ADHD. The manual and handouts were translated into Spanish with a few modifications. Results showed significant decreases in behavior problems and hyperactivity. A recent follow-up study using the culturally adapted version further revealed that significant and robust outcome measures resulted from large treatment effect sizes. Mothers reported reductions in “hyperactivity-impulsivity, inattention, and oppositional defiant and aggressive behavior problems, as well as a reduced level of parent-child related stress and improved parenting practices” (Matos, Bauermeister, & Bernal, 2009, p. 246). Additionally, in a single-case study with a Spanish-speaking foster mother and a 3-year-old Mexican-Chilean-Filipina child, PCIT proved to be effective; reports from other family members noted substantive behavior improvement (Borrego et al., 2006). Thus, we can deduce that PCIT can be used effectively across cultural groups.
There are three main components of PCIT: child-directed interaction (CDI), parent-directed interaction (PDI) and cleanup. Depending on the session being held, the components are presented in 5-minute segments with varying degrees of parent control required. CDI is characteristically the first stage in PCIT. Similar in approach to filial play therapy, this first stage creates an opportunity to strengthen the parent–child relationship. Because PCIT is utilized in the context of dyadic play, it is conducted in a room conducive to play (McNeil & Hembree-Kigin, 2010). Thus, a room designated for CDI should contain a variety of toys, crayons, paper, modeling compounds and other developmentally appropriate activities for a child. As with other play techniques, in order to give children the opportunity to determine the rules by which they will play, games with rules are generally excluded from a CDI playroom. Children engaged in CDI should be allowed to play with any or all of the items in the room. Encouraging free play indicates to the child that he or she is the creator of the play, not the caregiver. This approach allows the time to truly be child-directed.
Within CDI, the establishment of a positive therapeutic relationship is a crucial step in building a foundation for the introduction of compliance training. Compliance training is simply teaching a child to mind or comply over a period of time, through small compliance goals set by the parents. To lay the groundwork for this process during CDI, the parents are instructed to praise, reflect, imitate and describe their child’s play, while not asking questions, placing demands or criticizing the activities that transpire unless harmful to the child (McNeil, Eyberg, Eisentadt, Newcomb, & Funderburk, 1991).
Another essential concept introduced during CDI, includes fostering the enthusiasm and willingness of the parent. Although responding positively to a child’s free play during CDI may appear simple, parents often need considerable practice to master this response set. For example, one of the toys in our clinic is a Mr. Potato Head. Young children can be very creative in their placement of the various accessories that come with the toy. Often they will place an arm on top of the head, lips on the ear hole or eyes over the mouth hole. In PCIT, we view this action as an expression of creativity. However, when we observe parents in free play with their children, we often witness the parents limiting their children’s creativity by redirecting the placement of the appendages on Mr. Potato Head. Parents often say, “No, honey, the lips go here,” or “That’s not where the arms go.” Instructing parents to refrain from making such comments is generally all that a PCIT counselor needs to do. PCIT counselors understand that this is a difficult skill for most parents to master, and they teach parents the acronym PRIDE for use during CDI as well as other elements of PCIT. PRIDE simply stands for praise, reflection, imitation, description and enthusiasm (Eyberg, 1999). Table 1 provides some practical examples of desired responses from parents during CDI using the PRIDE approach.
Responses Using PRIDE model
||Parent: “Thank you for putting away the toys.”
||Child: “I’m drawing a dinosaur.”Parent: “I see. You are drawing a dinosaur.”
||Child is playing with a car. Parent gets a similar car and begins playing in the same manner.
||Child is playing with a toy airplane. Parent says, “You are making the airplane fly.”
||Parent: “Wow. Your drawing is very creative.”
In the second stage of PCIT, PDI usually is initiated once parents master CDI. Mastery is evidenced during the child’s play by the parents exhibiting proper implementation of the PRIDE responses. PDI also is conducted in the playroom or room selected for CDI. PDI consists of teaching parents how to manage their child’s behavior and promoting compliance with parental requests (Bahl, Spaulding, & McNeil, 1999). Parents should understand that PDI is more difficult for children than CDI and will likely be challenging for both the child and parent. When beginning PDI, parents must understand the importance of appropriate discipline techniques and receive training in giving clear directions to their children. Because children require a great deal of structure, professional counselors emphasize the importance of consistency, predictability and follow-through in this training (McNeil & Hembree-Kigin, & 2010). In order to initiate compliance training, parents practice giving effective instructions to their child. McNeil and Hembree-Kigin (2010) offered several rules for giving good instructions as part of the parent training element of PDI that can be conceptualized in the following ways: Command Formation, Command Delivery and Command Modeling:
- Give direct commands for things you are sure the child can do. This increases the child’s opportunity for success and praise.
- Use choice commands with older preschoolers. This fosters development of autonomy and decision making. (e.g., “You can put on this dress or this dress” rather than “What do you want to wear?” or “Wear this”).
- Make direct commands. Tell the child what to do instead of asking whether they would like to comply (e.g., “Put on your coat”).
- State commands positively by telling child what to do instead of what not to do. Avoid using words such as “stop” and “don’t.”
- Make commands specific rather than vague. In doing so, the child knows exactly what is expected and it is easier to determine whether or not the child has been compliant.
- Limit the number of commands given.
- Some children are unable to remember multiple commands. The child’s opportunity for success and praise increases with fewer, more direct instructions given at a time.
- When giving too many commands, parents have difficulty following through with consequences for each command. Additionally, the parent’s ignoring some minor behaviors may be best.
- Always provide a consequence for obedience and disobedience. Consequences are the quickest ways to teach children compliance. Consistency when providing consequences is the key to encouraging compliance.
- Use explanations sparingly. Some children would rather stall than know the answer. Avoiding the explanation trap prevents children from thinking they have an opportunity to talk their way out of it.
- Use a neutral tone of voice instead of pleading or yelling. Interactions are more pleasant in this manner and the child learns to comply with commands that are given in a normal conversational voice.
- Be polite and respectful while still being direct. This models appropriate social skills and thus interactions are more pleasant.
After teaching parents to deliver effective instructions and allowing time for in vivo practice, professional counselors introduce appropriate discipline strategies to be used in PDI. The in vivo coaching model utilizes an observation room with a two-way mirror and the ability to for the counselor to communicate with the parent via microphone. The focus on training includes communication and behavior management skills with additional homework sessions (Urquiza & Timmer, 2012). In a study by Shanley and Niec (2010), parents who were coached via a bug-in-ear receiver with in vivo feedback during parent–child interactive play demonstrated rapid increases in positive parenting skills and interactions. Of these strategies, timeout is the most common as it is “a brief, effective, aversive treatment that does not hurt a child either physically or emotionally” (Eaves, Sheperis, Blanchard, Baylot, & Doggett, 2005, p. 252). Furthermore, Eaves et al. (2005) wrote that timeout benefits both children with problematic behaviors and those who view the technique being used on other children, in addition to those children and adolescents demonstrating developmental delays, psychiatric issues and defiance. However, for the parent to experience timeout’s full benefit, the technique must be appropriately and consistently administered. Eaves et al.’s (2005) article, “Teaching Time-Out and Job Card Grounding Procedures to Parents: A Primer for Family Counselors” is an excellent article on timeout and why it is an effective intervention.
All aspects of timeout are reviewed with the parents, such as the rationale for timeout, where timeout should take place in the home, what to do when the child escapes timeout, what to do if the child does not comply with timeout, the length of timeout, what should happen right before timeout and what should happen right after timeout. Parents receive written instructions illustrating each step of timeout and offering guidance on how to implement the procedure. These discipline strategies may not be necessary if a child is motivated to be compliant. Determining compliance is often a very hard decision for parents to make. According to McNeil and Hembree-Kigin (2010) there are several rules used to help parents determine compliance or noncompliance.
- Parents must be sure that the instructions are developmentally appropriate for the child. If the child is asked to bring the orange cup to the parent, one must know that the child can determine which cup is actually orange.
- Parents should know that the request is completely understood by the child. If there are any questions about this the parents should point or direct the child to help him or her fully understand the request.
- Parents should allow the child approximately 3 seconds to begin to attempt the task. If the child has not begun to attempt the task by this time it should be considered noncompliance.
- Parents should state the request only once. If the child pretends not to hear the request, this should be considered noncompliance.
- Parents should not allow the child to partially comply with instructions. If parents accept half-compliance then children will often repeat the negative behavior because they know they can get away with it.
- Parents should not respond to a child’s bad attitude in completing a request. As long as he or she completes the instruction, it is compliance.
- Parents should consider it compliance if a child does what is asked and then undoes what is asked. Compliance is compliance no matter how long it lasts.
When a parent determines that a child is compliant, verbal praise should be provided. This praise should be given immediately and focus on the child’s compliance. Parents are encouraged to practice the skills of giving good directions by delivering multiple commands to the child. These commands are given during the playtime and may include requests to hand things to the parent (e.g., “Give me the red block”) or play with certain toys (e.g., “Place the blue car in the box”). This activity allows the child to practice following directions, while also affording the parent the opportunity to practice praise (McNeil & Hembree-Kigin, 2010). The child begins to learn that when he or she follows directions, his or her parents are very appreciative and excited. After the small tasks are accomplished, parents begin to place demands on the child that are less desirable, such as cleaning up the toys or moving on to another task (McNeil & Hembree-Kigin, 2010). By assigning less desirable tasks, parents find themselves in a position to practice a timeout procedure with the child. The professional counselor is there to model timeout and coach the parents when practicing timeout.
The third and final component to consider is called cleanup, which occurs as part of PDI. This time during the PCIT process is exactly what one might think; it is intended to teach the child to clean up the toys at the end of the parent–child interaction in both the counseling and home milieus. Cleanup should be done without the parents’ help but with the parents’ direction. Although this component may seem simple, it tends to be a challenging situation, as significant behavior problems often are displayed during this phase. The expectation is that this phase lasts 5 minutes, but time varies depending upon the behavior of the child (McNeil & Hembree-Kigin, 2010). Cleanup occurs only at the end of parent-directed play, not at the end of child-directed play, to avoid confusing the child about the role of parental help during cleanup. All three components—CDI, PDI and cleanup—are opportunities for behavioral observation and data collection.
According to McNeil and Hembree-Kigin (2010), there are six steps in conducting PCIT with a family. These authors have briefly described the contents of each step as well as provided guidelines for the number of sessions typically devoted to completing the tasks within each step. Step 1 requires one to two sessions for the intake process, Step 2 requires one session to introduce and teach parents CDI skills, and Step 3 requires two to four sessions in which the parents are coached on these skills. Steps 4 and 5 introduce and coach the PDI and may take up to six sessions. The final session is the follow-up session. These six steps complete a 10- to 15-session triadic training program.
Step 1 is the initial intake and can be accomplished in one to two counseling sessions, unless classroom or other observations are warranted. These sessions consist of assessing family dynamics, obtaining the family’s perception of the presenting problems, probing for insights into the current disciplinary beliefs and methods held by the parents, and observing the natural interactions between parents and child. In addition to the information-gathering component, the clinician defines the parameters of the sessions as well as the rules and expectations. Certain parameters involve an understanding by the parents that this CDI time is designated for the child to lead and for the parent to follow—a time often described to the parents as time-in for the child. Thus, time-in is defined as a time when the child facilitates play by selecting the type of play and initiating all play interactions.
The initial informal observation usually takes place in a sitting area while the family is waiting to visit with the counselor. In this informal observation, the counselor looks for “the child’s ability to play independently, strategies the child uses to engage the parent’s attention, parental responsiveness to child overtures, parental limit-setting, warmth of parent-child interactions, and evidence of clinging and separation anxiety” (McNeil & Hembree-Kigin, 2010, p. 20). After this stage of observation, a more formal observation is completed using the Dyadic Parent–Child Interaction Coding System (DPICS; Eyberg & Robinson, 1983). This observation is typically accomplished in three 5-minute increments in which behaviors and verbalizations are marked on the DPICS sheet. The formal observation occurs over the three PCIT stages previously described—CDI, PDI and cleanup. Following the initial observations, a third observation may be executed as a classroom observation. This type of observation is done with students who attend day care, preschool or elementary school, and allows one to see the child interact within his or her daily environment. Observation occurring in an alternate setting increases the chances of obtaining normative behavior (McNeil & Hembree-Kigin, 2010).
In Steps 2 and 3, the counselor presents and provides coaching on the CDI skills. Step 2 typically requires one counseling session. During this time the parents are taught the behavioral play therapy skills of CDI. The third step, coaching the CDI skills, may take two to four sessions depending on how the family adopts these principles into their daily interactions with their child. Coaching is described as modeling the behavior for the family, allowing the family to practice in session with feedback and prompts as needed, assigning the family homework to practice, and then repeating these steps until the parents are comfortable and fluent in the process.
In Steps 4 and 5, respectively, the counselor teaches and coaches the parents about discipline skills. These skills include both PDI and compliance training. Step 4 is typically accomplished in one session. Coaching may last from four to six sessions. Again, coaching is described as modeling, in-session practice with feedback and prompts, assigning homework, and evaluating success.
Step 6 consists of having a follow-up counseling session. This session is an opportunity to assess the family’s progress with proper implementation of each component of the PCIT model, gauge the strides made in compliance and assess the overall family satisfaction gained throughout the journey. Finally, one should use boosters to help parents maintain learned skills as they face new challenges with their children. Table 2 delineates the steps to implementing PCIT over a typical 10–15-session treatment plan.
Number of sessions
|Informal and formal observation
|Coaching CDI skills
|Teaching discipline skills via PDI and compliance training
PCIT was selected for use in the treatment of Manny, a 6-year-old Hispanic male diagnosed with autism and noncompliant to his mother. Like many children with autism, Manny had difficulty with unpredicted changes and verbalization of concerns. As Manny’s frustration with communication increased, he demonstrated stereotypies such as hand flapping and eventually progressed to tantrum behavior. The two goals of treatment were to increase the frequency of appropriate verbalizations and to decrease the frequency of inappropriate behavior including physical aggression, noncompliance and making noises. Manny was experiencing other issues related to autism, but his mother indicated that the behavioral problems were preventing him from making progress in other area.
As a result, we decided to conduct a functional behavior analysis prior to beginning treatment. This assessment of Manny’s behavior indicated that some of the behavior disruptions were a means of seeking attention, and therefore it was determined that PCIT would teach the mother to provide more consistent attention for appropriate behavior and to encourage appropriate communication more effectively. If needed, the addition of the timeout component was available after the mother began adequately attending to Manny’s appropriate behavior and ignoring inappropriate behavior.
The counselor explained the procedure and rationale for PCIT to the mother, including CDI, PDI and timeout. CDI was modeled and demonstrated with Manny. The mother was uncomfortable about being judged on her parenting skills, so it was decided that she would practice the skills at home using the Child’s Game nightly with Manny. The Child’s Game is simply defined as any free play activity the child chooses. The family would return to the clinic in 1 week.
The counselor reviewed CDI and had the mother conduct the Child’s Game for 5 minutes. During CDI, the counselor observed and noted the mother’s responses. The mother included 13 questions, one criticism and one demand in the 5-minute session. The mother praised Manny frequently, but did not use the other desired skills often. Manny was compliant with the demand that the mother gave and did not exhibit any of the disruptive behaviors. Following the CDI, feedback was given to the mother about increasing descriptions, reflections, imitations and praises, and reducing questions. The mother also was encouraged to recognize and praise communication attempts. Overall, the mother was directed to allow Manny to lead the play. When queried about CDI practice at home, the mother reported that the activity the family had used for the Child’s Game was watching television. Because there is no inherent interaction in television viewing, the mother was directed to provide a choice to play with action figures or art materials, both indicated as reinforcing by Manny, in place of video games or television. The Child’s Game was again given as homework.
The professional counselor reviewed CDI and viewed the family during the Child’s Game. The mother showed improvement using descriptions (16), reflections (3), imitations (1) and praises (15). She also limited her use of questions (6), criticisms (0) and demands (0). However, Manny exhibited disruptive behavior in 23% of the observed intervals. The mother also reported that Manny continued to be noncompliant and make noises at home. The professional counselor introduced PDI and timeout. Each was modeled with Manny, and his mother was allowed to practice and receive feedback. Homework was to continue the Child’s Game, issue 10 demands throughout the day and follow through with the brief timeout procedure. Also, the mother was asked to develop five house rules to bring the following week. To keep a record of the number of instructions with which Manny complied before going to timeout, and the number of timeouts per day, the mother received a homework compliance worksheet to keep for 1 week. This log allows the parent to record the homework—in this case, using the Child’s Game daily, issuing 10 demands throughout each day and recording the Manny’s compliance to each, and using timeout as indicated.
The counselor reviewed PDI, giving effective instructions and timeout to begin the session. The counselor then observed the family during CDI/PDI. The mother gave clear, concise instructions six out of nine times, only failing to wait before reissuing instructions when Manny did not immediately comply. Manny complied with all issued demands except when the mother reissued the demands too quickly. The mother followed Manny’s compliant behavior with praise statements four out of nine times. Manny was put in timeout for disruptive behavior and the mother used the procedure correctly. Manny demonstrated disruptive behavior during 33% of the observed intervals. A review of the homework compliance worksheet from the previous week indicated that Manny complied with 10 out of 10 instructions on 5 out of 9 days, and nine out of 10 instructions the remaining 2 days. The mother was encouraged to continue generalizing the skills she had learned throughout the day. The house rules developed by the family over the previous week were discussed and worded in positive statements and then introduced to Manny. The rules were explained and both examples and non-examples were modeled. Homework was given to continue incorporating the Child’s Game, issuing 10 demands in a brief period of time, using timeout as needed and recording compliance rates for 1 week.
The counselor reviewed PDI, EID, timeout and the homework compliance worksheet. The mother indicated that Manny had been compliant before timeout 10 out of 10 times for 6 days and nine out of 10 times for 1 day. The mother also noted that Manny had been placed in timeout for breaking house rules. The mother reported that Manny’s behavior had improved and he had had fewer tantrums related to schedule changes. She was encouraged to continue using the PCIT skills and adapting them to more situations. Because compliance was increasing, it was not necessary to continue CDI and PDI in this session. The family was given homework to continue the Child’s Game, PDI, using timeout as needed and recording compliance rates. This time, the family was to work at home for 2 weeks before the next session.
The counselor reviewed the family’s progress and addressed further generalization and concerns about daycare. The mother indicated that the child had been compliant before timeout on 10 out of 14 days. Two of the other days Manny had been placed in timeout 10 times and six times for violating house rules. The zero out of 10 compliance rating occurred during his birthday party, and the six out of 10 compliance rating was primarily the result of an unexpected trip to the grocery store. The family was again given homework to continue practicing generalizing CDI, PDI, using timeout as needed and recording compliance rates for 2 weeks.
The counselor addressed concerns including the beginning of school in a few weeks and provided suggestions to ease the transition. While the mother indicated that Manny had been compliant before timeout on only 4 of the previous 14 days, a review of the compliance rates revealed that on the other 10 days, Manny was compliant no less than 80% of the time. These compliance rates from various family settings were indicative of behaviors being generalized across settings. The mother also showed evidence of her generalization of skills by adapting the house rules to address new problematic behaviors. The family was encouraged to begin reviewing material learned in the previous session and work on behavioral skills such as sitting for appropriate lengths of time. The mother was instructed to continue both the use of her attending skills in order to reinforce appropriate behavior, as well as the use of the timeout procedure to diminish inappropriate behaviors.
For the final follow-up session, the counselor reviewed the family’s progress and determined that treatment goals were met. Concerns about how to get other family, friends and teachers to use PCIT skills with Manny were addressed in this final session. The family noted the improvements made as a result of PCIT and felt equipped to maintain the behavioral changes gained as a result of this counseling approach. Termination of the PCIT intervention was appropriate at this time; the case provided clear evidence of the application and utility of the PCIT model. Manny’s mother was offered the opportunity to continue interventions related to the other autism-specific issues that Manny was experiencing.
Professional counselors, whether working with children who have disruptive behavior or providing parenting training to families, should be knowledgeable of the application of various behavioral techniques in order to utilize them effectively and to teach them to parents. Researchers have proven that when implemented appropriately, PCIT procedures are effective in reducing undesirable and problematic behaviors in children and adolescents. Furthermore, it is clear that PCIT can be effectively applied to behavioral issues faced by children with special needs. We suggest that counselors who are interested in PCIT seek additional training to develop mastery of the techniques.
PCIT is a complex process that is often mistakenly viewed as simplistic. Thus, counselors who use PCIT without appropriate training will likely provide ineffective parental coaching. This point is especially poignant when working with children who have special needs. These children often present with numerous significant issues and deserve appropriate application of evidence-based intervention. We strongly suggest that counselors complete the web-based training provided by the University of California at Davis Children’s Hospital. The training is free and can be accessed at http://pcit.ucdavis.edu/pcit-web-course//. Given that PCIT is an effective approach and that the effectiveness of the model increases with appropriate education, professional counselors who further educate themselves on PCIT’s uses and applications can benefit their practices and the families they serve through the correct use of this empirically validated method of behavioral family counseling.
Counselors who are interested in PCIT also should consider advancing research related to counseling applications. While PCIT has been shown to be an effective intervention for autism and other disorders, more research is needed. We encourage counselors to consider implementation of studies that determine outcomes of PCIT for various child disorders and to conduct program evaluation for PCIT-based clinics.
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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Carl Sheperis, NCC, is the Chair of the Department of Counseling and Special Populations at Lamar University. Donna Sheperis, NCC, is an Associate Professor at Lamar University. Alex Monceaux is an instructor at Lamar University. R. J. Davis and Belinda Lopez are Assistant Professors at Lamar University. Correspondence may be addressed to Carl Sheperis, Box 10034, Beaumont, TX 77710, email@example.com.
Janeé R. Avent, Craig S. Cashwell
Researchers, scholars and counseling practitioners note the differences in help-seeking behaviors among racial and ethnic minority clients. With African Americans in particular, researchers attribute some of these differences to African Americans’ preference for relying on their spiritual and religious communities (i.e., the Black Church) for support in dealing with mental health issues rather than seeking help from professional mental health counseling resources. However, less articulated in the literature are the rationales behind this preference. Because of the salience of spirituality and religion in the African-American community, it behooves counselors to increase their knowledge of the African-American religious experience. This article provides an overview of the history of the Black Church, its theological foundations, implications for culturally competent counseling and recommendations for counselors in practice.
Keywords: African American, religion, spirituality, Black Church, mental health counseling
Kuczewski (2007) asserted that helping professionals often are charged to care for “vulnerable persons facing difficult situations and tragic choices” (p. 9). Often, within the counseling context, client spirituality is an important part of the healing process. There is substantial evidence that one’s religious life is a critical feature of the developmental process and can serve to improve one’s overall well-being (Cashwell & Young, 2011). Further, researchers have found positive benefits to incorporating spirituality and faith into one’s life, including improved physical (Matthews et al., 1998) and psychological (Joubert, 2010) health. Therefore, counselors are expected to assess the impact of a client’s spirituality and religion on his or her mental health and overall well-being (Cashwell & Watts, 2010). Moreover, attending to the spiritual needs of clients is an essential part of developing culturally sensitive treatment plans and recommendations (Kuczewski, 2007).
Not unlike other racial groups, African-American families rely on spirituality as a source of support as they face various challenges. These challenges include both systemic oppressions (e.g., overt racism) and familial stressors (e.g., parenting). Given these life stressors, perhaps spirituality and religion offer some explanation as to why African Americans are better adjusted and more psychologically well than some experts expect and predict (Bell-Tolliver & Wilkerson, 2011).
Nearly 80% of African Americans identify religion as important compared to only 50% of the general population (Pew Research Center, 2009). Further, a majority of African Americans identify as Christian, and 50% of African Americans attend church services weekly. The majority of African Americans attend a predominantly African-American church (Pew Research Center, 2009). Many African Americans identify God as a core aspect of their coping, and rely on their religion and spirituality during difficult life transitions (Bell-Tolliver & Wilkerson, 2011; Whitley, 2012). Additionally, African Americans assert that attending worship services and Bible study, being involved in their churches, having devotion time, and listening to religious sermons and gospel music allow them to conceptualize their struggles within the larger struggle between good and evil, or God and the devil (Whitley, 2012).
Because of the salience of spirituality and religion in the experience of African Americans, it behooves professional counselors to increase their knowledge and awareness of the African-American religious experience, particularly as it relates to psychological health. Several researchers (Ayalon & Young, 2005; Woodward, 2011) have found that African Americans tend to seek professional counseling at a much lower rate than other racial and ethnic populations. Further, African Americans often choose their spiritual leaders and churches as resources for their mental health needs instead of professional counselors (Ayalon & Young, 2005). Thus, one area of the African-American religious experience that needs further attention from counselors is the Black Church. The Black Church is the term used in popular culture and scholarly literature to refer to the overall institution that encompasses individual, predominantly African-American Christian congregations (Lincoln & Mamiya, 1990).
In order to understand the Black Church and the people who worship therein, counselors must familiarize themselves with the historical context and theological underpinnings that frame the Black Church and likely influence individual parishioners’ help-seeking behaviors. The purpose of this article is to provide a brief overview of the history and development of the Black Church, built upon unique theological foundations. These elements of history and theology have important implications for counselors working with religious African-American clients.
History of the Black Church
Similar to African-American communities, the Black Church has experienced change, progression, challenges, struggle and resilience. Counselors must understand the historical role and relevance of the Black Church in African-American communities in order to better understand African-American mental health help-seeking behaviors. This section will provide an overview of the Black Church’s inception during slavery, its role in the Civil Rights Era and its relevance in the lives of many African Americans in the 21st century. This history will provide counselors with a context for understanding the Church’s salience in the lives of many of their religious African-American clients.
The Black Church and Slavery
During slavery, many plantation owners forbade more than five slaves to gather at a time without supervision by a White overseer. Although slaves possessed a desire for religious and spiritual expression, this rule complicated their ability to assemble for worship services and stifled their sense of community and opportunities for fellowship. Thus, in fear of repercussions for breaking these rules, slaves resorted to informal worship gatherings in secret locations (e.g., swamps and wooded areas; see Frazier, 1963; Lincoln, 1973). Eventually, during the mid-1700s, these informal gatherings became less secretive and more visible (Pinn, 2011), laying the foundation for the institution that would be become known as the Black Church. The churches became the epicenter of the slaves’ community and a place of education and fellowship that slaves lacked elsewhere on the plantation.
During the genesis of the Black Church, plantation owners feared that if slaves were able to read the Bible, their proclivity to defer hopes of freedom until after death would decrease, and a surge of strength and demand for emancipation would emerge. Slave masters feared that slaves would acquire a comprehensive knowledge of Scripture that would illuminate the flaws and Biblical inconsistencies of a despotic slave system. With a comprehensive knowledge of Scripture, slaves would have an increasingly difficult time reconciling a Biblically based system that would capture and enslave innocent people (Taylor, Thornton, & Chatters, 1987). As predicted, slaves became discontented with their situation and used the Church as a means to bring about change. As slaves’ Scriptural knowledge grew, so did their frustration with organized religion, particularly Christianity. Slaves viewed Christianity as another vehicle used by Whites to advance oppression (Lincoln & Mamiya, 1990).
Slave masters and their families treated slaves poorly even though they worshipped together in the same buildings. Instead of church being a sacred haven away from maltreatment, it was another opportunity for Whites to exert their power, which became overwhelming for many Blacks (Lincoln & Mamiya, 1990). Thus, slaves incepted their own churches out of a desire to have their own worship places on Southern plantations and escape discrimination on Sunday mornings (Lincoln, 1973). Richard Allen inaugurated the first Black church of the Methodist denomination in 1807 (Wilmore, 1998). The formation of the Black Methodist churches was considered a visceral response to the Methodist tradition of having segregated churches for Blacks and Whites. This departure of Blacks from the Methodist Church was one of the first major civil rights protests by African Americans (Lincoln & Mamiya, 1990). Subsequently, African Americans formed predominantly African-American congregations of Baptist, Presbyterian and Episcopal denominations (DuBois, 1903), setting the stage for the prominent emergence of the Black Church during the Civil Rights Era. Slaves felt that they could be themselves and their status as slaves did not subsume their identity in these churches. These services provided therapeutic relief and a departure from the pressures and brutality experienced on the plantation (Wilmore, 1998).
In essence, church services and religious and spiritual resources operated much like counseling sessions. Slaves found hope in the Scriptural promises of a future void of oppression. They looked forward to death as a transition from suffering on earth to a promise of reward and deliverance in Heaven (Johnston, 1954; Wilmore, 1998). Slaves especially could relate to the persecution and torment of Jesus Christ, the pivotal figure of Christianity. In fact, slaves even likened the crucifixion experienced by Christ to the popularized practice of lynching Black men (Pinn, 2010; Terrell, 1998). Terrell (1998) further elaborated that the connection between Jesus and slaves also was related to the Bible story of Judas betraying Jesus for economic compensation. Slaves knew that White plantation owners betrayed, captured and brought them to America for others’ economic gain (Pinn, 2011; Terrell, 1998).
Although slaves faced horrendous conditions on plantations, counseling services obviously were not available as a support and therapeutic release. During this time, the Church was the primary resource for support and change during life challenges. It is likely that this proclivity to seek support from the Church began during slavery and continues today. This historical precedent could help explain why African Americans are less likely than many other racial/ethnic groups to seek support from professional counselors (Ayalon & Young, 2005).
The Black Church and Civil Rights
During the 1950s and 1960s, the Black Church became increasingly more autonomous as it began expanding doctrinal beliefs, electing leaders and even creating seminary institutions to educate its leaders (Lincoln, 1973). Further, the Black Church offered a platform for activists to promote messages of equal rights for African Americans (Chandler, 2010). The Black Church worked at both the macro and micro levels of society. For example, on the macro level, large institutions such as the NAACP garnered support (e.g., financial, emotional) from the Black Church (Chandler, 2010). At a more micro level, individuals with difficulty fulfilling financial obligations received economic assistance. The Black Church’s growing financial independence initiated the self-help doctrine, as African Americans could not rely on support from outside sources. African Americans learned that in order to survive they had to support themselves financially, mentally, emotionally and socially (Littlefield, 2005). It is possible that African Americans may still maintain this perspective, and therefore may be less likely to seek support from resources such as professional counselors.
Particularly during the Civil Rights Era, the Black Church was a place that Blacks could experience prestige, rank and authority otherwise denied them by outside institutions, which were typically dominated by the majority culture (Douglas & Hopson, 2001). Thus, many African Americans may be distrustful of the counseling relationship, as it may reflect the larger dominant culture from which they have experienced exclusion and oppression (Sue & Sue, 2013).
The Black Church in the 21st Century
While the Black Church of past decades struggled with achieving equal rights in the community, the contemporary Black Church faces its own set of unique challenges. These challenges are related to health (e.g., HIV/AIDS) and social issues (e.g., welfare reform, disproportionately high unemployment rates for African Americans; Billingsley & Caldwell, 1994). Nonetheless, African Americans have certainly made considerable strides in advancement compared to previous decades, notably in the areas of education. Many argue that these strides should be attributed, at least in large part, to the efforts of the Black Church (Byrd, 2001). These strides are particularly important as the African-American community faces issues such as disproportionate rates of physical illness, financial strains, anxiety, depression and familial concerns (U.S. Department of Health and Human Services, 2001; 2011). Although these challenges may seem daunting for African-American communities and the Black Church in particular, scholars encourage the Black Church to draw on the strength that brought it through turbulent times such as slavery and the Civil Rights Era (Billingsley & Caldwell, 1994). Given the historical involvement of the Black Church in all aspects of the individual lives of African Americans, it is understandable that many African Americans may view their local churches as a viable alternative resource to professional counselors. Therefore, counselors should involve themselves in African-American communities and familiarize themselves with local churches. Counselors have a unique opportunity to partner with Black churches in their communities to build trust, decrease stigma around help seeking, assist in combating concerns facing many African Americans and learning about the impact of Black Church theology.
Black Church Theology
Just as it is important to understand the historical context of the Black Church, it is imperative to understand the Black Church’s foundational belief systems in order to thoroughly understand its roles and functions. Theology unites the collective Black Church, but also differentiates between local congregations. Often, individual churches and denominations vary in theological principles, and therefore differ in how they execute beliefs about their purpose, roles and responsibilities (Barber, 2011; Lincoln, 1974). Often, the Black Church is mistaken as a homogenous grouping of individual churches. However, theological differences make this a false pretense (Barber, 2011). These theological positions can serve as overarching guiding principles and influences for parishioners’ individual lives and their choices, including decisions about seeking help from professional counselors.
Although theological differences exist, most Black churches unite in the theological belief that during worship services their members experience a personal visitation from Jesus. Typically, this theological notion guides the way services are conducted. This visitation could be manifested through rituals and practices such as shouting, singing gospel songs and hymns, or speaking in tongues. To that end, Moore (2003) noted these behaviors as examples of the liberal and animated worship that often is indicative of the Black Church. Other practices that are common to the Black Church and reflective of its theology may befuddle those unfamiliar with the structure of the Black Church service. For example, members of the Black Church may be more likely to reference God and Jesus interchangeably in spiritual practices, such as prayer, which could be confusing to some outside observers (Johnson, 2010).
These complexities could confuse counselors not immersed in Black Church culture. Moreover, many observers question the variations in theology and the often ambivalent character of an institution that can be so progressive on one hand, yet quite rooted in traditional theology on the other hand. This apparent ambiguity gives many observers pause (Douglas & Hopson, 2001). The religious theology that guides the Black Church can provide helpful insight for counselors interested in increasing their multicultural competence and understanding of African-American clients. Often, this theology can influence individual congregation members’ personal lives, including how they make choices regarding whether to seek professional counseling. The following section elaborates on various theologies and how they may manifest in African-American clients.
James Cone’s liberation theology is one of the most prevailing schools of thought in the Black Church (McBeth, 1981). According to liberation theology, African Americans took Christianity, traditionally perceived as a White man’s religion, and adapted it to the plights and triumphs of African Americans. Compared to other theologies, liberation theology is seen as a comprehensive theology because it considers how individuals view God and how they interact with one another. According to liberation theology, the Black Church offered oppressed Blacks a sense of freedom rarely experienced in their day-to-day lives. The Black Church was a place where African Americans had the opportunity to gather and vent about their problems as a community. Additionally, the Black Church was a place where change could be created and enacted (McBeth, 1981). While other theologies focus on Caucasians as oppressors, churches whose members ascribe to liberation theology tend to focus less on the oppression and more on the freedom that is felt when congregation members experience fellowship with one another (Burrow, 1994). Because slaves viewed the master–slave relationship as the epitome of evil, African Americans placed a significant emphasis on forming and preserving healthy relationships (Burrow, 1994; Douglas & Hopson, 2001). Liberation theology values addressing people holistically, emphasizing the connection of the body and the mind (Burrow, 1994).
Alternate Society Theology
Frazier’s idea of the alternate society is somewhat similar to liberation theology, in that he proposed that the Black Church should operate as a sovereign society where African Americans would be able to fully express their authentic selves (see McBeth, 1981). Frazier founded this theology upon the belief that Caucasians did not understand African Americans, and therefore could not adequately meet their needs (Frazier, 1963). Frazier endorsed the idea that the Black Church would be a separate nation within the United States and would meet the needs of African-American communities in ways beyond just the spiritual. Optimally, the Black Church would be able to produce education centers, financial institutions, housing and a social outlet (Lincoln & Mamiya, 1990). Ironically, Frazier acknowledged that this alternate society would further inhibit Blacks from successfully acculturating in the majority culture in which they were expected to live and function (Frazier, 1963). It is likely that churches ascribing to this theology believe they will be able to meet both the psychological and spiritual needs of congregation members. In fact, in churches where this philosophy is predominant, it is possible that members who seek guidance from church leaders may be discouraged from seeking services such as professional counseling outside the Black Church.
Other-Worldly and This-Worldly Theology
Other-worldly churches are those whose members believe in deferring freedom and reward until after death. In other words, these churches’ members are more accepting of present pain and suffering since they believe they will experience relief posthumously in Heaven. Spiritual songs birthed to comfort, direct and relieve Black slaves became a critical part of other-worldly theology. These songs have served as a reminder that earthly suffering is temporary and an eternal promise of heavenly peace awaits upon death (Cashwell & Young, 2011). Also, pastors serve as an important mouthpiece for other-worldly theology. During slavery, preachers often delivered sermons reminding listeners of life after death, a life that contrasted with the current reality of enslavement. Today, although some of the challenges facing African Americans may be different, some pastors continue to uphold messages of enduring present suffering and awaiting the promises that accompany death (Wilmore, 1998). Attendees of other-worldly churches may be less likely to present in counseling, but when they do, it is critical for the counselor to understand that the client may be less oriented to solving his or her problem and more oriented to focusing on life after death. Failing to understand and embrace this perspective might lead some counselors to focus prematurely on problem-solving tasks that might damage the therapeutic relationship.
Conversely, this-worldly churches typically advocate explicitly for Blacks to experience earthly freedom and happiness. For example, whereas a member of an other-worldly church may be satisfied with receiving physical healing through death, a member of a this-worldly church may pursue other avenues to minimize pain and suffering and delay death as much as possible (Lincoln & Mamiya, 1990). These ideas about suffering also could manifest in one’s attitudes about psychological health and needs for counseling. Clients from this-worldly churches may possess a greater sense of urgency to seek counseling during times of psychological discomfort compared to clients from other-worldly churches, who may be less inclined to alleviate emotional distress.
Recommendations for Counselors
Sue and Sue (2013) challenged culturally competent counselors to appreciate and incorporate clients’ history, worldviews and life experiences into the counseling relationship. One critical dimension of those considerations is clients’ religious and spiritual backgrounds (Cashwell & Young, 2011). Specifically, for religious African-American clients, this process involves examining the intersection of at least two social identities (i.e., what it means to the client to be religious and what it means to be African American; Roccas & Brewer, 2002). One essential aspect of many African Americans’ identity is the Black Church and the expression of its various theological perspectives. Thus, it is important that counseling practitioners, counselor educators and clinical supervisors are aware of the nuances of the Black Church and African-American religion and spirituality. Additionally, counseling professionals should be aware of the theology of each individual client’s local church, which could influence communal beliefs about symptomology and counseling. Counselors should use this information to increase understanding and inform accurate diagnoses, as well as competent treatment plans and recommendations (Association for Spiritual, Ethical, and Religious Values in Counseling [ASERVC], 2009; Cashwell & Watts, 2010). To that end, counselors can incorporate the following strategies in recruiting and retaining African-American clients who identify as religious and as members of the Black Church.
African-American clients active in churches with particular theologies (e.g., alternate society theology and other-worldly theology) may be disinclined to seek counseling services outside the church. Congregants may receive messages that the church can take care of all of their concerns, including mental health issues. Moreover, many churches (particularly within the alternate society theological tradition) may offer programs (e.g., financial seminars to address income-related stress) that attend to many of the needs of church members. In these cases, members may not feel a need to go outside to professional counselors. These clients may not voluntarily seek services from professional counselors even when their presenting concerns may warrant intervention. Thus, it is important for counselors to contact local Black Church congregations to establish relationships, form trust and increase visibility. Rather than depending on African Americans to initiate communication with mental health professionals, counselors can volunteer outreach services and host programs at local churches in an effort to increase access to African Americans. Counselors are expected to operate as advocates and proponents of change for their clients (Sue & Sue, 2013); often the Black Church is a hub of social justice advocacy efforts within African-American communities (Lincoln & Mamiya, 1990). Traditionally, programs in the Black Church have provided clothing, substance abuse services, tutoring, mentoring and nonreligious education services (Tsitsos, 2003). Counselors can partner with the advocacy efforts of the Black Church to help church members in need. These needs range from issues within the family to more systemic issues that affect a large number of African Americans (e.g., unemployment, poverty, AIDS/HIV, incarceration, anxiety, depression). These efforts may increase church members’ comfort level with counseling and decrease stigma associated with seeking help.
Specifically, counselors can connect with local pastors, since pastors are very influential in the Black Church and African-American communities in general (Billingsley & Caldwell, 1994; Lincoln & Mamiya, 1990; Mattis et al., 2007; Roberts, 1994). Often, the pastoral role extends beyond spiritual responsibilities, as the majority of African Americans prefer to seek psychological help from their pastors rather than professional counselors (Ayalon & Young, 2005; Chatters et al., 2011). Pastors may be more likely to refer congregation members to trusted counselors who are visible in their community. Counselors likewise have the opportunity to learn more about the pastors’ approaches to responding to mental health needs in their congregations.
In addition, theology is important for counselors in formulating client conceptualizations and treatment recommendations. In particular, counselors should be aware of when the client’s beliefs about healing juxtapose with the professional’s knowledge of science (Kuczeweski, 2007), and where counselor biases might be imposed on the client. For example, it is important that counselors are cautious in labeling presenting concerns as problematic when working with a client from a church that focuses on liberation theology. Such clients may choose to focus less on the presenting concern and instead take a more strength-based, optimistic perspective. Clients who attend churches that emphasize liberation theology may be open to more holistic treatment recommendations and reluctant to rely on psychotropic medications to alleviate symptoms. Thus, counselors should be aware of this preference when referring clients to a psychiatrist and suggesting medication as a part of the treatment plan.
Counselors are encouraged to work from theoretical orientations that are sensitive and inclusive of clients’ religious and spiritual identities (ASERVC, 2009). Since theology is an important part of many religious African Americans’ identities, the counselor should be careful not to approach the counseling relationship from a theoretical orientation that contradicts the client’s theological orientation. The biopsychosocial-spiritual model (Cairns, 2011: Engel, 1977) is a culturally sensitive theoretical framework that allows for a client to be holistically assessed from a biological, psychological, social and spiritual perspective. With the addition of the spirituality component to the traditional biopsychosocial model, the religious coping strategies of many African-American clients have been considered, addressed and appreciated (Clark, Anderson, Clark, & Williams, 1999). Further, the importance of addressing people holistically, emphasizing the connection of the body and the mind, is rooted in liberation theology (Burrow, 1994). In this regard, it appears that the spiritually founded liberation theology of the Church and the biopsychosocial-spiritual model may complement one another well. Leaders of the Black Church may not automatically articulate views using the language of the biopsychosocial-spiritual, but are likely to be able to do so using the language of liberation theology. Thus, it is incumbent upon counseling professionals to probe deeper into the intersections of Black Church theology and counseling models.
Counselors should educate themselves on current events and issues that may be affecting the African-American community in general (e.g., recent events in Ferguson, Missouri) and their clients in particular. Although many of these issues could be disheartening (e.g., disproportionate representation of African Americans in many vulnerable populations), counselors also should be aware of advancements made within the African-American community and work from a strength-based developmental approach that honors the uniqueness of the African-American community in general, and in particular, the Black Church. This perspective is vital, as many references to African Americans are negative, given their disproportionate representation in many vulnerable populations. It could be tempting for counselors to focus on the negative; however, focusing on the positive and acknowledging advancements could serve as a corrective experience for many African Americans.
Because of the centrality of relationships within the Black community, counselors should consider social supports, such as church members, who could serve as great resources for clients during and after the counseling process. For example, counselors should be open to consulting with spiritual advisors and referring clients to their pastors if deemed appropriate. Historically, church members have served as an extended family for many African Americans (Ellison, Musick, & Henderson, 2008; Lincoln & Mamiya, 1990). Therefore, fellow church members also could be included in the counseling process, both within and outside counseling sessions as resources and support systems.
Counselors should invite clients to talk about recent worship services and spiritual experiences in counseling sessions. It is important that this encouragement is made from a curious stance that is noncritical and nonjudgmental. This invitation not only allows the client to integrate his or her spirituality into counseling, but also allows the counselor to learn more about the client’s religious background and preferences, as well as his or her specific church culture.
A counselor also can incorporate creative interventions that integrate a client’s religious and spiritual influences. For example, the counselor could invite the client to compile a list of his or her favorite gospel songs as a musical chronology and emerging life song. This process allows client and counselor to extrapolate themes and values that are important to the client (Cashwell & Young, 2011; Duffey, 2005). Given the historical importance of spirituals, the client could write songs or use existing songs to help articulate presenting concerns to his or her counselor. Additionally, the counselor becomes privy to the client’s spiritual values and theological beliefs by listening to song lyrics. Similar interventions might include asking the client to create a list of favorite Biblical stories or specific scriptures. Additionally, the counselor can ask the client to construct a spirituality genogram, which can provide invaluable information about the role of the Church in the client’s family and its influence on their individual lives (Cashwell & Young, 2011).
Researchers, scholars and counseling practitioners have noted the differences in help-seeking behaviors among racial and ethnic minority clients. With African Americans in particular, researchers have attributed some of these differences to African Americans’ preference for seeking help from spiritual resources rather than professional counseling resources. When exploring the mental health help-seeking behaviors of African Americans, it is imperative to pay particularly close attention to the role of religion, the Black Church and theology in the counseling experiences of many African-American clients. Learning more about various theological traditions and working from a culture-centered framework can substantively increase the quality of counseling 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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Janeé R. Avent, NCC, is an Assistant Professor at the University of Texas-San Antonio. Craig S. Cashwell, NCC, is a Professor at the University of North Carolina-Greensboro. Correspondence can be addressed to Janeé R. Avent, 501 César E. Chávez Blvd. DB 4.344, San Antonio, TX 78207, firstname.lastname@example.org.
Rose Anelyn Visaya-Ceniza
This study aimed to determine the psychosocial health status of women artisanal miners in the Philippines. Their socio-demographic characteristics and psychosocial health status are described to formulate a self-efficacy enhancement program to respond to their needs. This study utilized a descriptive multiple case study design. Primary data were gathered via a simple questionnaire regarding the respondents’ socio-demographic profile and psychosocial health status. Other primary data sources included key informant interviews, respondents’ journal entries, observations and outputs during the structured learning exercises, focus group discussion transcripts, and a researcher’s log. Documentary reviews also were utilized to obtain additional facts. The respondents were selected through a fishbowl method. Results show that the participants’ coping process, attitude of perseverance and stress management have a moderate impact on their ability to manage life experiences. The study resulted in a proposal for a self-efficacy enhancement program to improve the psychosocial health of women artisanal miners.
Keywords: women miners, psychosocial health, coping process, stress management, self-efficacy
In March 2008, the theme “Babae, Yaman Ka Ng Bayan” [Woman, You Are a Treasure of the Nation], emphasizing the worth of women in nation building, was bannered to celebrate Women’s Month in the Philippines. In Barangay Puntalinao, Banaybanay, Davao Oriental, Philippines, active artisanal and small-scale magnesite mining activities are visible to the community and visitors. Banaybanay is the last municipality of Davao Oriental, bordering the municipality of the Pantukan, Compostela Valley Province. Women join men at tilling and extracting minerals from steep mountains. This site was visited in October 2007 for an environmental scanning and initial investigation. The idea of conducting a study was discussed with the artisanal miners and they showed interest in the benefits of the study.
The southern part of Mindanao is rich in mineral resources. Nickel reserves are worth $215 billion (USD), copper reserves are worth $6.49 billion and gold reserves are worth $2.01 billion. Mindanao accounts for 48% of the country’s gold and 83% of the nickel reserves. According to Ambassador Li Jinjun, investors believe that the mining industry is the “ace” of Mindanao. In agreement, former resident of the Republic and current congresswoman of the province of Pampanga, the Honorable Gloria Macapagal Arroyo has made the revival of the mining industry one of her key tools in sustaining the country’s economic growth (Bautista, 2005).
According to the United Nations Development Program (1999), women involved in mining are more likely to be family-centered than men and spend their earnings on food, clothing, education and agriculture. In the Philippines, women artisanal miners’ daily routine involves direct exposure to sunlight, climbing difficult mountains, tilling and extracting minerals, and carrying heavy sacks of rocks, in addition to household chores and family obligations after work. Moreover, some women are undergoing the physiological discomforts of menopause.
In a focus group discussion (FGD) on perseverance, the women artisanal miners reported that they can bear the heat of the sun, the hazards at work and the workload at home in order to preserve their families and provide what is needed. Their husbands’ incomes are not enough for their families’ basic needs, typical of the life conditions of the rural poor in the Philippines. According to the Barangay Captain [Puntalinao community leader], these women persist at low-paying quarrying activities to subsist. Women artisanal miners manifest the spirit to persevere in life through their backbreaking work hours. This labor includes quarrying the rocks with a hammer and wedge, hitting the rocks in succession to break them into small pieces, packing them in a sack (which generally weighs no less than 110 pounds), and carrying the sacks to the buyer’s loading area. Workers aim to fill 25 sacks per day on average, which are sold to a local buyer for 10 pesos each in order to sustain daily family needs.
According to Greenspan (1992), households ideally spend up to 10% of total income to raise one child, 18% for two children and 26% for four children. Since many families lack the resources to raise children, the per-child share drops dramatically with each child. A household with four children spends 25% less per child than a household with two children. This information suggests that the sufficiency of the family economy depends on the number of children in the household, and thus establishes the need to work harder to ensure family survival as the number of children in the family increases. It is not surprising to find an extended family system among Filipino families (Mercado, 1974) and to see children helping their parents at income-generating endeavors.
The miners’ common statement, “Maayo na lang ning pagpamato, bisan ginagmay kaysa wala jud sapi” [Even if mining gives us insufficient income, it is better than having nothing at all], reveals the working poor perspective that is important in considering ways to improve the miners’ psychosocial well-being. These women, ranging from young adults to elders, are vulnerable to stress; their self-efficacy is a powerful personal resource in the coping process (see Lazarus & Folkman, 1987).
While studies have explored the experiences of miners, these studies have failed to grasp fully the psychosocial health situation of women artisanal miners in Philippine rural communities. Since mining is a major contributor to the country’s economy, artisanal mining is expected to spread soon to other rural communities. Therefore, the experiences of community women require attention in order to better anticipate their emerging psychosocial health issues. The theoretical frameworks utilized in developing this study included Erikson’s (1963) psychosocial development theory, which posits that each person experiences psychosocial crises or internal conflicts linked to life’s key stages, which define growth and personality. Social-cognitive and self-efficacy theory (Bandura, 1992, 1997), defined as beliefs about one’s capabilities to produce levels of performance that influence one’s life, also was utilized to formulate this study.
The author utilized a descriptive multiple case study design. Primary data were gathered using a researcher-constructed questionnaire that investigated each respondent’s socio-economic profile and psychosocial health status. Other primary data sources included key informant interviews, respondents’ journal entries, observations and outputs during the structured learning exercises (SLEs), FGD transcripts, and the researcher’s log. Documents provided by the barangay [community] secretary also were reviewed.
Twenty-six women ages 26–70 volunteered. Eight were between 35 and 43 years old and eight were within the ages of 53–61. Five of the respondents were between ages 44 and 52 and two respondents were 26–34 years old. The artisanal miners participating in the study were identified from the barangay list and via the assistance of the barangay secretary. Based on the socio-demographic data drawn from the selected women miners of Barangay Puntalinao, Banaybanay, Davao Oriental, the respondents generally belonged among the rural poor migrant settlers and had low levels of educational attainment. Most participants were mothers responsible for large families and obliged to participate in mining to sustain daily family needs. Most participants owned their homes; however, the houses were located on rental lots, causing some degree of insecurity in terms of permanence of residence.
A 21-item survey, translated from English to Cebuano, provided a socio-demographic profile and psychosocial health status of each respondent, covering perseverance, stress management and coping processes. It was clustered into three areas: personal data, family structure and housing arrangement. Items 1–6 aimed to determine level of perseverance. Items 7–16 covered the impact of stress management styles, and items 17–21 determined the impact of coping processes on managing life circumstances. Responses were tallied using the following scale: 1.00–1.99 indicating that the given life experience had a high impact on psychosocial health status over the past month, 2.00–2.99 indicating moderate impact on psychosocial health and 3.00–4.00 indicating low impact.
Other primary sources of data included key informant interviews, respondents’ journal entries, observations and outputs during SLEs, transcripts from the FGD, and the researcher’s observation logs from her 3-day community immersion. The key informants included the Barangay Captain, the Barangay Health Worker and a sari-sari [small grocery] store owner, all of whom were interviewed during the researcher’s community immersion. A formal approval to conduct a study in the area was requested from the Barangay Captain. The Barangay Health Worker was interviewed about health conditions among the women miners and the barangay’s health programs for women. An interview also was conducted with a sari-sari store owner who had firsthand knowledge of the women residents’ consumer behavior and lived in a house located at the mining compound. Daily logs recorded what was witnessed and experienced during the immersion. The Barangay Puntalinao Development Plan (2000) also was used to gather basic community information such as the history, demography and topography of the barangay.
SLEs were conducted after the baseline data on psychosocial health status were obtained. The SLEs focused on coping processes, perseverance and stress management. During each SLE, a lecture was conducted and an assignment given for follow-up discussion with the group before the activity concluded. Outputs from the SLEs formed part of the data for the multiple case studies. A FGD with 14 randomly selected miners was conducted after the last SLE, focusing on coping processes, stress management and perseverance. Outputs from the FGD were utilized to validate and expand on the data extracted from the survey questionnaires and SLEs. The psychosocial health status of the respondents was monitored three months after the conclusion of the last SLEs. It provided feedback on the sessions’ lasting effects on the psychosocial health management of the respondents, despite the assessment of medium-term effectiveness, not included in the objectives of the study.
Socio-Demographic Profile and Psychosocial Health Status
The general conditions of poverty resulted in multiple burdens, including reproduction. The high numbers of respondents’ children may have indicated that respondents spent much of their childbearing years within marriage. Six of the artisanal miners had four offspring. One of the respondents had nine and another had 14 children. Eighteen miners had children aged at least 22 years old. Three respondents had children 1 year old or younger, which suggests that more time and effort were needed to exert in mining to provide the needs of these children in the early stages of human development. Aside from economic needs, data implied that the women miners lived with their husbands and managed time for child care, despite long days at the mines.
Coping processes. The results showed that Filipino women artisanal miners’ coping processes had a moderate impact on recent life experiences for which they employed these coping strategies. The respondents had the ability to handle different trials in life, but the ability to use common coping strategies had a fair influence on being able to manage life circumstances well. It was evident from the women’s disclosures that multiple workloads consumed their being. However, the coping processes they employed had a low impact on solving family problems.
“Lisod kaayo ang among kahimtang labi na og mag-abot ang mga problema sa pamilya” [Our situation is very difficult most especially when the entire family encounters problems at the same time]. Because the women miners were responsible and accountable for problems encountered by the entire family, they became concerned when the family experienced difficulty. This finding was similar to findings from the United Nations Development Program (1999), which reported that women were more likely than men to devote resources for family upkeep, food and children’s education. Furthermore, prioritizing the needs of the family demonstrates adherence to the traditional Filipino value of kagandahang loob [compassion] (Miranda, 1992).
Among the 14 respondents who participated in the SLEs, coping behavior was utilized regarding problematic circumstances with their husbands’ vices and behaviors such as drinking, infidelity, physical abuse and financial neglect. Marital cases brought to the barangay office are usually reconciled through forgiveness and for economic reasons. Problems related to their children included participants’ daily absence from home, no contact while away from their children, early marriage and inability to support their children. According to the key informant, mining is considered a survival strategy despite its health risks, low compensation and daily starting time, as early as 5:00 a.m. (see Table 1).
According to one informant, a Barangay Health Worker who happened to be a neighbor of the miners, the miners often channeled time and effort into their mining in order to regain a sense of self-worth and focus on caring for their families, despite health risks and low compensation. During the FGD, the women miners mentioned using prayer as a coping strategy. Some Filipino women miners join religious organizations in order to express their feelings with fellow members. Miners’ journal entries indicated that they believed their present situation was their destiny.
Psychosocial Health of Women Artisanal Miners at Barangay Puntalinao, Davao Oriental in Terms of Coping Processes
|Coping Processes Indicator
|Coping strategies employed
|Conflicts with in-laws or household members
|Conflicts with immediate family members
|Conflicts with friends
|Being taken advantage of
|Lots of responsibilities
Note. LI = low impact, MI = moderate impact, HI = high impact.
Perseverance. The women miners’ attitude of perseverance had a high impact on their effective socializing with their neighbors. During FGDs, participants shared that the community had not encountered cultural problems because of respect for one another; in addition, most participants belonged to the Cebuano tribe. Based on the observation log, the women artisanal miners cared for each other and showed respect to everyone by treating each other without bias. Jocano (1999) wrote that the Filipino value delicadeza [being proper], is manifested, for instance, when one does not abuse a friendship by doing something that would be hurtful or embarrassing to a friend. This value is apparent in the practice of sabot that allows women to express and meet their needs for help without sacrificing their pride and dignity. Enriquez (1978) discussed kapwa as a mode of Filipino social interaction which he defined as “recognition of shared identities as well as the compassionate generosity to others in need.”
Based on the statement of the sari-sari store owner who was a neighbor of the respondents, the women miners usually incurred credit for food to be paid the following day. This practice of sabot [agreement] maintains social relations based on asal [consideration] as discussed by Jocano (1999) and kagandahang loob [compassion] as depicted by Miranda (1992). The moral undertone of these terms is best expressed by the Filipino concept of pakikiramay, or going out of one’s way in order to share the sorrow of others in times of crisis (Miranda, 1992). The practice of sabot, therefore, addresses the survival needs of the women in a manner that does not compromise their self-esteem, kindness and generosity.
It is evident that the women artisanal miners are insecure in terms of their housing, because most of their homes are built on property owned by other people. The participants’ attitude of perseverance had a moderate impact on dealing with the knowledge that the lot their houses were on could be revoked at any time. At the time the study was conducted, most of the houses had to be relocated to accommodate a road-widening project by the provincial government. Houses were uprooted and moved at least 10 meters from the road, causing the miners uncertainty about where to locate, or how far a potential relocation might be from the workplace.
Individual case studies showed that the women artisanal miners performed multiple roles including mother, wife, grandmother and household manager, as well as miner. Since these women were willing to sacrifice for their family, it was important for them to nurture their attitude to persist. Though they had the determination to continue with their various roles, they also needed to recharge from time to time. Their ability to manage the toll of their physical and psychological loads led them to a greater sense of self-efficacy. Such a sense allowed them to select challenging settings, explore their environments or create new ones (see Table 2).
Psychosocial Health of Women Artisanal Miners at Barangay Puntalinao, Davao Oriental in Terms of Perseverance
|Having your contributions overlooked
|Hard work to look after and maintain house
|Gossip about yourself
|Findings your work too demanding
|Financial conflicts with family members
|Experiencing high levels of heat
|Ethnic or tribal conflict
|Dissatisfaction with your physical fitness
|Dissatisfaction with your physical appearance
|Disliking your daily activities
Note. LI = low impact, MI = moderate impact, HI = high impact.
Stress management. The women miners’ stress management styles had a moderate impact on their management of the stressors they encountered. Thus, there was room for improvement in their repertoire of stress management techniques to help prevent exhaustion or burnout. The data, moreover, showed that the miners did not harbor insecurities regarding their physical appearance and fitness. In addition, because of the forgiving attitude of the participants, violent family conflicts were avoided and rarely compounded their difficulties. Instead of borrowing trouble, the women generally opted to forgive.
Data showed that the stress management styles of the women miners had high impact with regard to viewing the future and remaining optimistic and hopeful. As for techniques employed, one participant stated that watching teleseryes, or television series, was a common means of relaxation among the women in the community. Women often finished doing household chores in the evening and watched television. Based on the study log, the miners and their children and grandchildren typically gathered inside the house around 7:30 p.m. to watch television. Teleseryes provided a medium for sympathetic catharsis. For instance, when the women witnessed someone’s misfortune, they compared it with their own and felt better afterward. When they viewed someone being oppressed on television, they tended to feel better about their own situation. When the oppressed character fought back, the viewer identified with the character’s desire to oppose malevolent forces. More importantly, sympathetic catharsis brought stress to a manageable level (see Table 3).
Psychosocial Health of Women Artisanal Miners at Barangay Puntalinao, Davao Oriental in Terms of Stress Management
Stress Management Indicator
|Stress management techniques
|Unsatisfactory housing and conditions
|Trying to secure loans
|Too many things to do at once
|Take on the burdens of the entire family
Note. LI = low impact, MI = moderate impact, HI = high impact.
The Barangay Health Worker who was interviewed for the study happened to own a karaoke machine and stated that the women miners sometimes came over and sang whenever they had extra money (each song costs one peso on the videoke machine).These were occasions for the miners to bond and socialize as they sang, danced and laughed. During the FGD on stress management, it was mentioned that playing bingo also was one of the miners’ common pastimes, providing another social activity and an opportunity to connect with others and meet a very basic human need for the women.
Based on the survey of psychosocial health status, stress management strategies had a low impact on addressing stressful daily activities. According to one participant, “Usahay kapuyon ko og makabati og sakit sa lawas tungod kay dili lalim ang akong trabaho” [I get tired sometimes and do not feel good physically because my work is not that easy].
The participants in this study indicated a need to enhance their coping strategies to cope with adversities in their lives. While they have the fighting spirit, their coping strategies could be improved further. A sense of self-worth must be further developed for the participants to be aware of their respective capabilities to exercise control over stressful situations. If this need was met further and more positive self-efficacy achieved, the miners would be better able to enhance their psychosocial health status.
Most of the women artisanal miners married at an early age and were financially unable to finish school. They were driven to engage in mining for many years to sustain the basic needs of their families. Most of the respondents have husbands and children who mine as well. More often than not, children are forced to discontinue school and begin work to help support the family. Despite being poor, the women have not surrendered to the trials of life, holding on to aspirations and possessing the following self-related cognition: “I can do it.” This attitude allows them to overcome the lack of opportunities by mining as a way to earn income and sustain the needs of their families.
Mining is perceived as God-sent and affords the women an opportunity to be self-reliant and gain a measure of control over their daily experience. Most of the respondents have persevered for the sake of their children and grandchildren. In addition to their labor, physical and emotional abuse from their husbands increases their suffering; yet they tend to be forgiving. Coleman (1998) advocated the therapeutic value of forgiveness as follows: “Forgiveness is a must in any family problem where there has been deep hurt, betrayal, or disloyalty” (p. 78). If there can be no reconciliation, forgiveness is the process that enables the forgiver to move on with life unencumbered with the pain of betrayal. Madanes (1991) further asserted, “The only way we can survive from day to day without emotional breakdown is by forgiving and forgetting” (p. 416). This study did not explore why the women miners forgive the wrongs done to them. It was found, however, that the women tend to forgive their husbands, although some still nurse hurts and resentment.
For the women, mining plays a major role in survival. The activity is described as a means of livelihood, a family bonding activity and source of hope for life. Furthermore, it also is seen as a chance to establish good relationships with colleagues, or pakikipagkapwa, and to enjoy work despite discomfort and hard work.
Most participants aim to build a semi-concrete house with comfortable rooms in a lot that they would own. In addition, the security of their residence is questionable when affected by the road-widening project of the provincial government. Still, the respondents expressed optimism as symbolized by the blooming flowers and abundant trees in their drawings (their output during their SLE), depicting joy and love in their households (see Appendix for an example).
Women artisanal miners in the Philippines would benefit from learning strategies to effectively address problems they encounter. They need to develop a sense of personal efficacy for approaching threatening situations with assurance that they can exercise control over these threats. The miners are hopeful and optimistic; therefore, it would be worthwhile to engage them cognitively and affectively and to facilitate decision-making that would allow them to gain insight into how to better manage resources and improve psychosocial health.
Given the socio-demographic characteristics, as well as the presentation of different life experiences, aspirations and psychosocial health status of the women artisanal miners, this study discovered that the miners would benefit from an intervention that revitalizes them, despite day-to-day stressors. Although the women are able to cope with various life difficulties, there is a need to enhance their coping strategies for managing stress. The miners should be more aware of their capabilities to exercise control over their own functioning and over the events that affect their lives, and thereby develop a stronger sense of personal efficacy. If these needs are met and self-efficacy achieved, the women miners will be able to enhance their psychosocial health status.
Optimism is commonly manifested in the stories told by the women artisanal miners. According to Bandura (1992), people with high assurance of their own capabilities approach difficult tasks as challenges to be mastered rather than threats to be avoided. Such an efficacious outlook fosters interest and engrossment in activities. A person who believes in being able to cause events can conduct a more active and self-determined life course. This can-do cognition mirrors a sense of control over one’s environment, and reflects the belief of being able to master challenging demands by means of adaptive action. This attitude also can be regarded as an optimistic view of one’s capacity to deal with stress (Bandura, 1992; Maddux, 1995; Wallston, 1994). This study reveals the importance of helping women miners enhance self-efficacy to maintain psychosocial health.
After the exploration of the women miners’ psychosocial health status, the researcher discovered that the miners need an intervention in order to be revitalized despite the various obstacles they encounter from day to day. They need training on how to maintain a positive outlook on life and how to believe in their potential to endure as a mother, wife, grandmother and daughter, as well as person. Considering the lifestyle and psychosocial health status of the women miners in terms of perseverance, coping processes and stress management, the self-efficacy enhancement program focuses on effective ways of creating a strong sense of efficacy among the miners in order to sustain the perseverance needed to succeed.
The stories of the women artisanal miners suggest that their coping processes, attitude of perseverance and stress management strategies have a moderate impact on their ability to manage their respective life experiences. As the 14 individual case studies were examined further for their psychosocial health status, the author found that most of the women artisanal miners face economic crises as well as maternal and marital problems. Despite these challenges, they manifest a forgiving attitude, which reflects the notion that such sacrifice is necessary for the sake of the family’s survival.
The miners also are optimistic about the future, an attitude that was manifested during the sharing of their aspirations in life through drawings. All participants mentioned positive life visions and goals. Flowers and trees were commonly drawn, which symbolized the participants’ desires to have happy and harmonious families. Children wearing togas and parents pinning ribbons on a graduation day also depict the participants’ yearning for the education and advancement of the next generation. Semi-concrete houses with comfortable rooms are illustrated to show longing for comfort and security in living conditions. All these aspects of the drawings (see Appendix) demonstrate that the women artisanal miners have plans and hopes in life that give them the determination to persist. Optimistic processes are an essential key to gaining a sense of self-efficacy.
The women miners possess the optimistic attitude to carry on, but there is room for them to discover more about how to control their functioning and manage their psychosocial health status more effectively. Therefore, it is necessary to help them enhance their coping strategies and stress management techniques.
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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A Miner’s Drawing of Life Aspirations
Rose Anelyn Visaya-Ceniza is the Head of the Guidance Counseling and Testing Center of the Davao Oriental State College of Science and Technology, Guang-Guang, Dahican, and a practicing psychologist at St. Camillus Hospital of Mati, Inc. Correspondence can be addressed to Rose Anelyn Visaya-Ceniza, DOSCST, Dahican, 8200 Mati City, Davao Oriental, Philippines, email@example.com.
The author previously published portions of this article: “An Exploration of the Psychosocial Health Status of Women Artisanal Miners in Mindanao, Philippines” in Procedia: Social and Behavioral Sciences, 91, 505–514.
The purpose of this study was to identify perceptions about a school counseling internship program at a university in Adana, Turkey by determining counseling interns’ perspectives on the effects of the internship program and supervisors’ perspectives on interns’ professional development. Data were collected from nine school counseling supervisors, 11 school counseling interns, 11 guidance teachers and 34 students who attended group guidance activities during counseling students’ internships. Data were analyzed using content analysis, and findings suggested that counseling interns have the opportunity to perform activities that school counselors normally perform, and that interns become competent in performing these activities. The internship program helped interns become competent at applying professional knowledge and skills. Additionally, with the assistance of interns, school counselors were able to provide proactive counseling services to students. The study suggests that positive, constructive feedback and advice from supervisors are essential for interns to be successful in completing internship activities in a positive and confident manner.
Keywords: school counseling, school counseling internship, professional development, counselors-in-training, Turkey
Professional school counselor identity is defined as an integration of professional training with personal attributes in the context of the profession (Nugent & Jones, 2009). Brott and Myers (1999) stated that the development of professional school counselor identity can serve as a frame of reference for implementing work roles and making important decisions. Professional identity develops as part of the experiential maturation process over time, which begins in training and continues throughout a person’s career. A school counselor’s professional development starts during training, evolves during entry into the profession and continues to develop as the school counselor identifies with the profession (Brott & Myers, 1999).
Professional identity has internal as well as external aspects (Auxier, Hughes, & Kline, 2003). Internal aspects are defined as an individuation process derived from a cycle of dependence and autonomy as counselors-in-training (CITs) gain counseling skills (Brott & Myers, 1999). During training, students rely on guidance and support provided by supervisors as external authorities. Gibson, Dollarhide, and Moss (2010) found that CITs needed external validation and assurance from experts, especially at the beginning of their training. Alternatively, counseling students felt much stronger, more confident and more positive toward counseling at the end of their internship and practice, with anxiety levels decreased and feelings of personal accomplishment increased (Nelson & Jackson, 2003). Researchers in Turkey found that the sense of efficacy increased among counseling students who conducted group guidance activities (Atici, Özyürek & Çam, 2005), while their counseling skills evolved throughout the school counseling internship program (Atici & Ulusoy, 2010). Both an increase in positive feelings and a decrease in negative feelings were observed from the beginning to the end of the term (Atici et al., 2005; Atici & Ulusoy, 2010).
The interpersonal aspect of professional identity development involves the role of the professional community in shaping the new professional (Auxier et al., 2003; Gibson et al., 2010). In the context of counseling, new professionals are socialized in the language of counseling, learn professional expectations, and learn to become a counselor through observation, supervision, consultation and practice (Gibson et al., 2010; O’Byrne & Rosenberg, 1998). This process also is conceptualized as entering a professional culture in which CITs learn appropriate attitudes, values, thinking styles and problem-solving strategies (Dollarhide & Miller, 2006).
It can be concluded that school counseling training programs can contribute to the professional development of CITs. For instance, in the United States, school CITs learn and apply the standards and models of the American School Counselor Association (ASCA, 2003, 2005, 2012) and practice counseling activities under supervision via practicum and internship. School counseling interns at some universities in Turkey (e.g., Çukurova University) perform classroom guidance activities at primary and secondary schools, putting into practice what they have learned. In addition to classroom guidance, these students conduct activities such as small group guidance, individual counseling and consultation; apply individual assessment techniques and psychological measurement tools; and observe school counselor practices. Conducting these activities as CITs can result in a contribution to interns’ professional development, in which being prepared as a school counselor and establishing confidence are preeminent. Other factors that contribute to students developing a sense of competency during their internship include observing school counselors’ collaborative skills, engaging in the profession, perceiving their activities as successful and acknowledging their own professional development (Atici & Çam, 2013). Studer (2005) found that internship experience can provide opportunities for school counseling interns to engage in a number of activities concerning school counseling, while Nelson and Jackson (2003) indicated that internship experiences had positive effects on interns by giving them the opportunity to apply what they had learned and develop a sense of being a counselor. Similarly, Jett and Delgado-Romero (2009) found that prepracticum service learning and internship programs at schools and community agencies facilitated counseling students’ professional development.
Henderson (1994) reported that supervision provided learning opportunities within a school context for counseling students. Furthermore, Sutton and Page (1994) suggested that supervision can function as a bridge between competencies in counselor education programs and the skills required in an actual work context. Receiving feedback from supervisors, along with having varied experiences during internship, appears to positively affect professional identity development. Findings from several studies have shown that support and assurance from university tutors and school counselors as supervisors also have a positive effect on professional identity (Nelson & Jackson, 2003); especially when school counseling students receive constructive, nourishing and encouraging feedback (Özyürek, 2009). Receiving feedback and advice from university professors, having a relaxed supervisory atmosphere in which counseling students can express themselves comfortably, and observing and modeling themselves after working school counselors all lead to improvement and motivation as a counselor (Atici & Çam, 2013).
However, Portman’s study (2002) revealed that a group of CITs had not received supervision at their assigned schools, but had received clinical supervision from university supervisors during practicum and internship. Some student counselors found this supervision helpful, while others thought that they did not have a real supervisory experience. Accordingly, Özyürek (2009) found that supervisory courses and supervision were insufficient in school counseling internship programs.
Coker and Schrader (2004) developed a comprehensive, collaborative and integrative school-based practice in order to prepare students to better fulfill the demands of the school counselor’s role and to help students learn to work at schools as leaders and advocates. In this school-based internship, in addition to individual and group counseling, students consulted with teachers and parents, attended team meetings, and advocated for the personal, social and academic development of students. During internship at a primary school, students were able to perform the required number of hours for practicum, counsel real clients in an actual school context, and develop a clear counseling approach and orientation for working with young people at school under the guidance and supervision of researchers. They also experienced the various roles of a school counselor including advocate, consultant, collaborator and leader.
School counseling internship programs can facilitate the development of specific skills required for school counseling and general preparation for the profession. In addition, it can be concluded that during school counseling practice sessions, the support provided by the supervisor and role model at the school is influential in teaching school counselor roles and encouraging professional identity development.
Several studies have shown that counseling interns experience positive emotions such as confidence, success and efficaciousness by the end of the internship (Atici & Ulusoy, 2010; Nelson & Jackson, 2003), and their counseling skills and professional and personal development evolve (Atici & Çam, 2013; Atici et al., 2005; Atici & Ulusoy, 2010; Jett & Delgado-Romero, 2009). Additionally, researchers have found that counseling interns have opportunities to experience several activities (Studer, 2005); to obtain their supervisor’s help, support (Nelson & Jackson, 2003) and feedback (Atici & Çam, 2013); and to develop their own personal counseling approach (Coker & Schrader, 2004). However, since these studies focused on counseling interns or counseling students, there is a need to investigate the impressions of working school counselors (who also function as supervisors at school) about school counseling internship programs, as well as to explore counseling students’ perspectives on the contributions of school counseling internship programs, supervisors and supervision to their professional development.
The present study focuses on school counseling supervisors’ perspectives on school counseling internship programs, their assistance and contribution to school counseling interns, and their recommendations for solving problems and conducting internships more effectively, as well as on counseling students’ opinions about the effects of their internship experiences and supervision on their professional development. The aims of this study were the following: (a) to identify school counseling supervisors’ views on the effectiveness of school counseling internship programs, (b) to assess the assistance provided to school counseling interns, (c) to gather school counseling supervisors’ recommendations for effective internship methods, (d) to investigate counseling students’ perceptions about the effects of internship programs and the process of supervision on their own professional development, and (e) to examine the views of secondary school students and their teachers on the effectiveness of group guidance activities conducted by counseling interns.
Participants included nine professional school counseling site supervisors and 11 school counseling interns. A purposeful sampling strategy (Patton, 1990) was used to collect data from information-rich cases. Specific school counseling supervisors were invited to participate in the study because they were identified as effective models for interns. Six female and three male counseling supervisors working in different schools voluntarily participated in the study. Five counselors had a master’s degree in counseling, and the remainder held degrees at the undergraduate level. Of the professional participants, three worked at a high school, five worked at a middle school, and one worked at a primary school in Adana, Turkey. Their experience ranged from 9–22 years, while the number of years spent supervising counseling students ranged from 2–10 years. Eleven school counseling interns enrolled in school counseling internship courses at one university in Adana also participated in the study. These interns were selected because they provided written data from both the students who participated in their group guidance activities in the schools and from these students’ teachers regarding their views on the effects of group guidance activities. An agreement of consent regarding the purpose of the study, the research procedure and confidentiality was obtained from each of the participants. All participants voluntarily accepted participation in the study.
Description of Course Process
Counseling students in this study each attended a course for school counseling internship, taking place at three schools and at one university in Adana, Turkey. They went to their respective schools for half a day each week during the autumn and spring terms in their fourth year of undergraduate study. During internship, counseling students conducted group and classroom guidance activities, consulted with teachers and parents, applied assessment techniques and measurement tools, interviewed individual students, and observed other school counselors working. One group guidance session was observed by a university supervisor and/or a professional school counselor site supervisor, who provided feedback about the intern’s activity.
Supervision at the university was 3 hours per week; all students and the university supervisors attended this session. During this session, counseling students discussed their activities and difficulties, and received feedback from supervisors and other students in the group. At the end of the term, students submitted a portfolio of all of their activities during the internship, with a general evaluation of the supervisory course and supervision; the school, school personnel and school counselor; and the contribution of the supervisory course to their professional and personal development.
Interviews and data from documents were used as qualitative data-collecting tools. The researcher interviewed nine school counseling supervisors individually using a semistructured interview guide. Open-ended questions were used to elicit supervisors’ views on the effectiveness of the school counseling internship program, problems encountered during internship, their recommendations and the assistance they provided. Interviews were recorded digitally and transcribed.
Three different documents were used in this study. Counseling interns were asked to evaluate their school counseling internship programs, supervisors and supervision in terms of their professional development at the end of the term. Interns wrote about their internship programs and submitted these written texts to their supervisors as part of their final portfolio. High school students who attended group guidance activities and their teachers provided their ideas about the effects of group guidance activities on participating students’ behavior by responding to an open-ended question. These written forms of data were collected from 11 counseling students, 11 teachers and 34 students who attended group activities conducted by six counseling students.
Analysis of Data
The researcher analyzed qualitative data by using content analysis. To begin with, an open coding procedure was followed (Strauss & Corbin, 1990). Interview transcripts and written documents were examined by line, sentence and paragraph, and a code or a name representing a particular idea, activity or event was given. Then the researcher combined related codes into categories. For example, in coding data regarding influential factors in conducting group guidance activities, the codes of enthusiasm, not feeling anxious and feeling efficacious were grouped under the heading emotional state. Axial coding was carried out to identify main categories, their subcategories, and relationships between main and subcategories. For example, one of the categories that identified influential factors in conducting successful group guidance activities was titled counseling student–related. Emotional state and professional skills were placed under the counseling student-related category as subcategories. Finally, in the selective coding stage, the main categories and their subcategories were grouped together.
Credibility and Trustworthiness
Activities performed to ensure validity included data and method triangulations by collecting in-depth data in face-to-face interviews with school counseling supervisors, and examining and analyzing documents produced by counseling interns, teachers and students who attended group guidance activities (Denzin, 1994). Next, the researcher presented direct quotations from counselors and examined research results in terms of meaningfulness and consistency, comparing his findings to those from different data sources in the literature (Miles & Huberman, 1994; Yıldırım & Şimşek, 2008).
The researcher kept a detailed explanation of the data collection and analysis procedure and raw data for reexamination by others. In order to enhance trustworthiness, the researcher attempted to acknowledge personal assumptions and prejudgments and prevent those biases from interfering with the data analysis and interpretation process (Miles & Huberman, 1994; Yıldırım & Şimşek, 2008). Since a single researcher conducted the study, he tested for consistency (Robson, 1993) by comparing the codes derived from the initial coding process with those obtained from a second process. The researcher computed the proportion of agreement by dividing the number of agreements by the sum of the number of agreements and number of disagreements, resulting in a consistency value of 0.84.
Results are presented in three categories as follows: (1) results derived from the analysis of interviews with school counselors, (2) counseling students’ views on the roles of school counseling internship programs and supervisors impact on their professional development, and (3) school students and their teachers’ views on the contributions of group guidance activities to participating students. Throughout the Results section, direct quotations from school counseling supervisors are labeled with a C, quotes from teachers are labeled with a T and quotes from counseling student interns are labeled with an S.
Results from Interviews with School Counseling Supervisors
School counseling supervisors’ perspectives on counseling students’ practices and effectiveness. According to the results of the interviews, the counseling students carried out group and classroom guidance activities during their school counseling internships. Counseling individuals, leading seminars with students and their parents, applying individual assessment techniques and measurement tools, and consulting with teachers and parents were among other activities. Examples of the supervisors’ views on school counseling internship programs are presented below:
They did nine group guidance activities with their own group and three classroom guidance activities . . . [they also provided] consultation and applied an individual assessment technique. I encouraged them to interview students and their families. I have talked with them and asked what they think about the [client’s] problem, which questions they can ask, and what they can do about the problem. (C8)
They did group guidance activities, . . . applied individual assessment techniques, evaluated the results, and consulted with teachers about the interpretation of the results. They did classroom guidance activities, for example conflict resolution, anger management, study skills, and career guidance, that must be carried out by school counselors. They also did individual interviews with students. (C9)
All of the supervisors surveyed acknowledged the positive work outcomes of the counseling interns. The school counselors emphasized the positive effects of the school counseling internship program by using terms like “significant contribution” and “very helpful.” They also shared their impressions that the interns’ work was reflected in the behavior of students, parents and school personnel. They also witnessed the students’ understanding of their activities, counseling concepts and topics, and expressed positive feelings regarding the interns.
Supervisors stated that the effects of the counseling internship program could be seen more specifically in personal and social areas such as self-awareness, self-acceptance, behavior change, interpersonal skills, awareness and control of emotions among school students. Additionally, school students improved in the areas of career decision and coping with career indecision during career counseling; and in areas of education such as study skills, exam anxiety and academic achievement. According to the supervisors, the counseling students benefitted from gaining experience in classroom management and individual counseling, improving communication skills, expressing themselves, and enhancing efficacy feelings. At the same time, the interns helped school counselors carry out their work plans and lessened their workload, providing counseling services to many more students and presenting proactive counseling services. Professional school counselors themselves benefitted from the internship experience by learning new ideas from the counseling students and enhancing their own motivation levels. For example, a counselor summarized the counseling students’ motivating effect in the following quote: “They helped me renew myself. . . . [When counseling interns] came to my school, my enthusiasm and excitement increased. I learned new . . . warm-up activities when I observed them” (C3).
The following quote demonstrates how the counseling students’ work was helpful for the supervisors, the school students and the counseling interns themselves: “They definitely made a contribution. I got positive feedback from teachers and students in terms of their contribution” (C6). Another school counselor made the following remarks:
They contributed a lot. . . . My interns were very active in working with me. In particular, some of them worked . . . as a second counselor in the school. They made . . . classroom presentations. They improved themselves, as well as benefit[ted] the students. . . . Their practices lessened my workload. (C2)
A third school counselor stated, “As I said before, I am trying to reach many students. . . . Interns contributed a lot. They also gained experience in classroom management, communication with students and getting feedback from students to increase their efficacy” (C4).
According to the school counseling supervisors, counseling interns learned the most during group work. Interns improved their overall effectiveness, which included emotional comfortableness, readiness, eager communication, leadership, group management and counseling skills. One school counselor explained, “Counseling students’ skills of communication, group management and leadership greatly affected conducting successful activities” (C1). In the following quotes, two counselors explained how they used observation and feedback in the process of evaluating activities:
I go to a classroom guidance activity with [interns], especially when they have classroom management problems. They probably feel anxious during the first one or two activities, and then become relaxed. For this reason, after each activity we make an assessment for 5–10 minutes: How was the day? What did they do? What difficulties did they come across? They shared all sorts of things they would like to talk about. Furthermore . . . if there [is] something which I do not like, if they are reluctant to do activities or do something against school rules, I talk to them and express my concerns. (C2)
When they have difficulties I try to help them. Upon completion of their activities, we make a general evaluation of the day, focusing on topics like: How was the activity? What was the difficulty? What did they do to cope with it? (C5)
School counselors’ assistance to counseling interns. Interview data regarding professional school counselors assisting counseling internship students revealed four themes: (a) observation, evaluation and feedback; (b) giving information and advice; (c) organizing counseling activities; and (d) being a model.
One counselor explained how she helped by observing group guidance activities and giving feedback and advice about reference books: “I prepared an observation form [for interns]. Then we sit and talk all together as a group. Thus, I create an atmosphere in which they benefit from each other. I advise them on books to be read and give information about the counseling approaches I prefer.” (C3) Another counselor explained that she gave individual feedback after classroom guidance, as follows:
I observe [an intern] twice, once at the beginning and once at the end of the term, while they are conducting a classroom guidance activity. I give feedback about their deficiencies as a school counselor and advice on how they can rectify these. . . . I find this way of giving feedback is positive and useful. (C4)
Problems in internship programs and recommendations. When school counseling supervisors were asked about problems they encountered during school counseling internship programs, four said there were no problems and they liked the way the internship program was carried out. On the other hand, five counselors mentioned a few problems related to counseling students, such as school student nonattendance, coming as a large group to internship sessions, being unmotivated toward the internship program and disobeying some rules. There also were a few problems arising from the school, school personnel and students, such as difficulty organizing groups of students; complications in scheduling appropriate days, times and places for classroom, group and individual work; school personnel’s negative attitudes and behavior toward counseling interns; and students’ reluctance to engage in group work.
One counselor expressed her ideas about the negative effects of nonattendance and the difficulty in observing counseling interns when they came in a large group to internship sessions in the following quote:
When a group of interns is too large, it is difficult for me to help them as I had planned. For example, they are not able to observe while I am interviewing students. Of course, I get permission from students for the presence of . . . counseling interns during interviews . . . it is a big problem for me when . . . interns do not come to counseling sessions on the assigned day. . . . All of the students in that group come to me one by one and ask whether . . . interns will come to the group activity, or why she/he is not coming. I am responsible to the principal, since the teacher leaves the class with me for a group guidance activity at a certain time. So, if the interns don’t come, I have to do the activity by myself, meaning extra work for me. (C2)
The school counseling supervisors made recommendations for enhancing the quality of school counseling practices rather than solving problems. Although these recommendations were mainly for counseling interns and counseling activities, school personnel, students and university supervisors also were subjects of these recommendations. In particular, the school counselors suggested that certain activities should occur more frequently, such as consultations, seminars and classroom guidance sessions. Other suggestions for contributing to the school counseling internship programs were the following: learning legislative procedures and the tasks of the board of counselors at the school, keeping interview and council records, learning to solve specific problems like abuse and enuresis, presenting case studies about specific problems, observing school counselors’ work, planning warm-up activities to precede group work, and not using old-fashioned individual assessment techniques which lead to labeling students.
In terms of duration and timing of the internship programs, suggestions were as follows: school counseling internship should start during the intern’s second or third year of school, junior students should observe senior students during their internships at school, and time assigned for internship should increase. Regarding observation and evaluation, it was recommended that both site supervisors and university supervisors observe and evaluate counseling interns, and that school counselors meet at the university to revise the internship program from time to time. To this end, a school counselor expressed her ideas in the following quote:
There should be a meeting with school counselors, who accept counseling interns at their school, at the beginning and end of the year to talk about what they are going to do and to assess how the term went, what they did, was it useful? Coming together and making an overall assessment would be helpful once or twice a year. (C1)
Furthermore, another school counselor emphasized the necessity of adding consultations, seminars and case presentations to the practices currently being carried out, as follows:
I think the internship program should be revised in the light of a school counselor’s actual duties at school. For example, seminars for parents and students, case examinations and presentations should be required from . . . interns. They should work on a specific case example and present this case study to the program supervisor. For instance, the interns may work with a student with exam anxiety and prepare a report on this case. They must work with specific problems that they will meet when they begin to work as a school counselor. There is a lack of practical experience in case work and consultation in the internship program currently operating. However, we do mostly consultation at school. (C2)
The Role of Supervisors and Internship in Interns’ Professional Development
Interns’ evaluation of university supervisors and supervision. When counseling students’ evaluations regarding supervision and supervisors at the university were analyzed, the following three categories emerged: contribution to the practice process, gaining experience and preparing for professional life, and feedback and advice. In the contribution to practice process, students pointed out that the supervisory course was productive and helpful. Counseling students learned a lot from the course that enabled them to create solutions to problems, recognize their mistakes, and share their activities and difficulties, thus making school counseling activities much more functional. Interns watched video recordings of group activities conducted by themselves or their peers in the supervisory course. The students stated that watching these recordings was beneficial, giving them a chance to see their mistakes, find solutions to problems and benefit from feedback. One counseling intern explained as follows:
Due to time limitations our supervisor could not come to observe our work at the school. But, by watching video recordings of the activities we did, and giving detailed feedback in supervisory sessions, our supervisor helped us to see our mistakes. I was lucky to be in her group. (S5)
According to the interns, school counseling internship programs contributed to their professional development and professional life by providing the opportunity to apply counseling knowledge and skills. These internship programs, which are considered indispensable for professional development, enabled counseling students to establish their own approaches and prepare themselves for future difficulties.
A main distinctive theme that emerged regarding university supervisors was the giving of feedback and advice. Feedback was considered helpful and efficient for solving problems that occurred during the program, selecting and organizing activities, conducting productive group activities, correcting mistakes, overcoming obstacles, coping with anxiety, and creating opportunities for self-evaluation. Advice provided by supervisors was seen as helpful enabling students to find solutions to problems and difficulties, to achieve desired results from group activities, and to feel pleased with their progress. Counseling interns also received feedback and advice from their peers; one stated, “I think sharing our experiences, and giving and taking feedback from each other contributed to our development. The school counseling internship course was effective for gaining experience, getting practice and improving professionally.” (S1)
Interns’ evaluation of school supervisors and supervision. Two themes in this section were assistance to the practice process and negative impressions of supervisors at schools. Regarding assistance to the practice process, counseling interns explained that school counselors coordinated counseling practice for them by organizing groups of students and scheduling appropriate days, times and places for activities during the internship program. The supervisors also shared their experiences and knowledge, and provided opportunities for counseling students to observe some of their interviews with students and parents. The counselors demonstrated various methods of communicating with students, interviewing parents and other aspects of school counseling, and presented an example for which to learn the job. School counselors gave feedback and advice to assist counseling interns in learning how to be school counselors, provided professional information and prepared them for professional life (e.g., files, meetings, reports, minutes of meetings).
Regarding negative impressions, interns reported that some site supervisors, although relatively few in number, were reluctant to share their experiences or communicate with the interns because of time limits. For this reason, these supervisors did not organize individual counseling sessions or time for consultation, application and interpretation of measurement tools, and did not give any feedback. One counseling student said, “I think we did not get enough feedback from our site supervisors/school counselor due to their being busy. This was a negative aspect of our internship at school” (S9). Another intern said the following: I wish I had done more activities like individual counseling, learned more techniques and that the school counselor had shared her experiences more with us. Due to time limitations we didn’t have a chance to do some of the activities. (S1)
Roles of School Counseling Internship Programs in Interns’ Professional Development
Self-improvement in counseling skills. School counseling internship programs enabled counseling students to build their skills and become productive in the areas of group guidance, classroom guidance, individual counseling, seminars and consultation. These activities were followed by improvements in counseling skills, application of theoretical knowledge, management of behavioral problems and group management skills.
Other contributions that counseling students mentioned included gaining professional knowledge, achieving milestones of the profession, preparing for the profession, discovering coherence between their personalities and the profession, and gaining insight into the ways that working with students of different ages and social backgrounds contributed to their professional development. The following quote may be taken as an example of counseling students’ ideas about the internship program:
It was full of experience and learning for me. Both the help of supervision and my own efforts have given me good preparation for my career. I believe that the things I learned this year will facilitate my future education and will be milestones in my professional career. (S7)
Positive feelings during internship. Being happy (n = 9) was the most common positive feeling that counseling students experienced during internship. It was followed, in order, by feeling efficacious (n = 6), confident (n = 5), eager (n = 5), proud (n = 2), and relaxed and good (n = 1), both personally and professionally. Interns used words such as “like” and “enjoy” to describe their experience. Counseling students expressed that they were happy when they were successful and helped students, received supervisors’ support and feedback, and worked with certain supervisors at the university. They also emphasized that their efficacy and confidence had increased as they did successful work, attended supervision sessions and received feedback from supervisors. Similarly, with the support of the supervisors, they became eager about counseling activities and exercises, taking pride in positive feedback, enjoying the profession through their internship experiences and showing positive emotions such as feeling relaxed. One student expressed the positive effects of feedback as follows: “Having constructive feedback and advice, and our supervisor giving importance to everybody’s work, made me feel happy. Due to her feedback, I felt little anxiety while I was doing activities. This course enhanced my confidence in doing school counseling work.” (S5)
Teachers’ and Students’ Views on Group Guidance Activities
Students’ gains from activities. Ninth graders attended group guidance activities on communication, assertiveness, social skills and career counseling, and produced written documents acknowledging what they had gained from the activities. When the documents were analyzed, it was clear that students had positive results and acquisitions such as self-awareness, getting to know people, introducing themselves to others and skills of communication, assertiveness and relationships. Students also expressed positive feelings and comments regarding group activities, such as happy, relaxed, enjoyable, peaceful, eager and responsible. Students who attended career counseling group activities reported that at the end of these activities, they had learned about several occupations; identified majors and occupations they would choose in the future; recognized their abilities and interests; understood relationships and consistencies between occupation and ability, occupation and interest, and occupation and personality; and acknowledged factors that affect pursuing a career.
Data suggested that students had positive views of the counseling interns. In order, these positive adjectives were as follows: understanding, being good, good listener, respectful, gentle, being confidential, sympathetic, patient, reliable, optimistic and cheerful. Furthermore, the students also thought that the counseling interns produced solutions to problems. However, in contrast to these positive features, school students also mentioned a few negative aspects of the activities, like hesitating to tell their secrets to the group, not understanding how to fill in forms or finding solutions offered to the group as useless.
Teachers’ ideas about classroom guidance activities. When teachers’ views about the effects of these activities with students were analyzed, three themes emerged as follows: interpersonal relationships, communication skills, and behavioral and motional changes. Teachers pointed out that they observed development mostly in interpersonal relationships and communication skills such as active listening, being respectful and getting to know each other, enhancing group transactions, attachment and cooperation, and sharing. The teachers also brought attention to behavioral development and changes in problem-solving skills, participation in lessons, assertiveness and protection of their rights, taking responsibility, and correcting mistaken goals. According to teachers, students showed positive emotional changes, meaning that they enjoyed, were enthusiastic about and were satisfied with the activities, which enhanced self-confidence and motivation toward their lessons. Two teachers expressed the positive effects of the activities in the following quotes:
Some of my students in particular began to come to school with positive feelings such as happy, eager and ready. Others of my students who have had problems in expressing themselves and participating in the lessons started to cope with shyness/timid[ity] and participated in the lessons with confidence. (T1)
There are positive changes in students’ behavior like problem solving and communicating with their peers. They used to fight to solve their problems, but now they have learned to stop, wait and listen to each other to work things out. I assume that group guidance activities are very useful in teaching students how to work out their problems. (T2)
According to findings derived from interviews with counseling supervisors, counseling interns gained experience in classroom guidance, group guidance, individual counseling, seminars, consultation, and application of individual assessment and measurement techniques during school counseling practices. It can be said that these are the essential parts of a school counselor’s work, and having had these experiences, interns are more likely to be prepared for the school counselor role. Similarly, interns’ evaluations of the supervisory course in the internship program showed that through the program, counseling students both developed and enhanced their counseling skills through conducting school counseling-related activities. Coker and Schrader (2004) also found that in school-based practice, counseling interns did individual and group counseling and consultations, attended team meetings, and advocated for the personal, social and academic achievement of students. The findings of the present study parallel those of Brott and Myers (1999), who concluded that professional identity development begins in training and continues throughout a person’s career life. Additionally, the current results are considered consistent with Studer’s (2005) findings, that internship provides opportunities to do school counseling activities; with Nelson and Jackson’s (2003) findings, indicating that internship has positive effects on application of knowledge, skills and development of insight; and Jett and Delgado-Romero’s (2009) study, showing that doing internship at a school or hospital facilitates counseling students’ professional development.
All school counseling supervisors in the present study noticed the positive outcomes of the school counseling internship programs, for the school students who attended the counseling activities, for the interns and for the school counseling supervisors themselves. These school counselors witnessed school students’ cognitive, emotional and behavioral changes as a result of attending counseling activities, and received positive feedback from teachers and parents regarding counseling interns’ work. School counseling supervisors’ impressions and observations regarding the benefits of counseling practices, in terms of personal–social, educational and career development of students, were consistent with teachers and students’ evaluations of the effects of the activities. For example, classroom guidance teachers pointed out that they observed changes in students who attended group guidance activities with regard to interpersonal relationships, communication skills, and emotional and behavioral changes. Furthermore, students who attended these activities also said that they acquired skills in the areas of communicating, building relationships, practicing assertiveness, and making decisions about majors and careers, and that they gained positive feelings toward the activities. It should be emphasized that there were similarities in students’ and teachers’ perceptions about the effects of counseling practices. These similarities were especially apparent in personal–social changes and positive emotions regarding activities. School counselors emphasized that counseling students assisted them in carrying out their work plans and lessening their workloads; thus, they were able to provide preventative counseling services to many more students.
According to school counseling supervisors surveyed, counseling students benefitted from counseling internship by gaining experience in classroom management and individual counseling, improving communication skills, and enhancing self-efficacy. Similarly, counseling students mentioned their acquisitions in the application and development of school counseling knowledge and skills, feeling happy and efficacious as a result of the successful internship activities they completed. These findings parallel the findings of studies carried out by Atici et al. (2005), Atici and Ulusoy (2010), and Atici and Çam (2013).
The professional school counselors indicated that they were able to help counseling interns by observing them and giving feedback, providing information and advice, organizing counseling practice sessions, and being role models. The counseling interns mentioned the same kinds of help provided by their school counseling supervisors. These results parallel the findings of Atici and Çam’s (2013) study, which indicated that school counselors help counseling interns by coordinating school counseling practice sessions, being role models, and sharing materials and resources. Coker and Schrader’s (2004) findings indicated that counseling interns develop a clear counseling approach with the guidance of supervisors, and are able to experience the school counselors’ roles of collaboration, advocacy, leadership and consulting with the guidance of professional school counselors.
A few counseling interns in the current study had negative impressions of school counseling supervisors who were reluctant to share their experiences, organize practice sessions and give feedback. As a result, counseling students could not benefit from the experiences and skills of some school counselors. This finding is supported by the results of a study by Atici and Çam (2013). Similarly, some CITs in Portman’s (2002) study did not receive supervision at schools, and although they found that clinical supervision from the university supervisors was useful, there were deficits in the internship program, and they did not receive a real supervised experience. According to these results, it can be concluded that school counselors’ inability to create an environment in which they function as role models and provide feedback may affect the professional identity development of some counseling interns in a negative way.
According to school counselors surveyed in the present study, counseling interns’ readiness, desire, comfort, self-efficacy, communication, leadership, group management and professional skills played roles in the effectiveness of group activities. This finding is consistent with the opinions of counseling interns regarding the contributions of the school counseling internship program to their professional development. Counseling interns reported that as a result of successful work they did, and during successful work, they felt happy, relaxed, eager and efficacious; thus, they acknowledged self-development in conducting group guidance activities and building counseling skills and group management skills. These findings parallel results from other studies, such as that CITs experience positive feelings like confidence, achievement and efficacy (Atici & Ulusoy, 2010; Nelson & Jackson, 2003) and develop their counseling skills, and that school counseling activities contribute to professional and personal development (Atici & Çam, 2013; Atici et al., 2005; Atici & Ulusoy, 2010; Jett & Delgado-Romero, 2009) and provide opportunities to do various activities (Studer, 2005).
It is clear that feedback and advice from university supervisors were useful and effective in planning and carrying out successful activities, finding solutions to problems and assessing of activities. Watching video recordings of sessions enabled students to receive feedback from professional school counseling supervisors and their peers, which was very helpful and improved the conducting of group guidance activities. Similarly, in interviews, school counseling supervisors pointed out that their feedback for counseling students impacted the success of group activities. Counseling interns also reported that their feelings of happiness, pride, efficacy, confidence and love for the profession increased as they did successful work and received feedback from supervisors. These findings shared similarities with results in the literature, indicating that assurance and support from university supervisors and site supervisors in schools positively affect professional identity (Nelson & Jackson, 2003), that counseling students find feedback constructive, encouraging and helpful for improving their professional development (Özyürek, 2009). The literature also shows that nurturing feedback and advice from university supervisors and a relaxed supervision atmosphere have motivating effects (Atici & Çam, 2013), and supervision functions as a bridge between competencies in the counselor education program and the skills required in workplaces (Sutton & Page, 1994).
School counseling supervisors reported that they met few problems during internship, and they solved these problems by talking with counseling students and expressing their expectations. The fact that school counselors encountered few problems emphasizes that they liked and were satisfied with the internship program, although they made recommendations in order to further develop the internship programs and counseling exercises. These recommendations were mainly to increase some activities and to start school counseling internship programs earlier than the last or fourth year of study.
From the results of the study, it is apparent that school counseling internship programs not only contribute to the professional development of counseling students, but also help professional school counselors and school students in several aspects. As a result, school counseling coordinators and school principals should organize school counseling internship programs, so as to benefit from counseling interns’ assistance in providing counseling services to as many students as possible.
Since feedback and advice given by university supervisors were considered useful and effective in planning and carrying out successful activities, university supervisors should provide feedback by either observing counseling students or monitoring their activity records from the internship program. This feedback is vital for counseling interns, especially when they need to see and correct their mistakes and assess their professional skills with the guidance of an external authority.
Although there were only a few complaints about school counseling supervisors’ reluctance to assist counseling students during internship, their disinclination is still an obstacle to the professional development of counseling students. Therefore, the university counseling educators should consider this issue when deciding to which school and school counselors they will send their counseling interns, and they should discuss this potential problem with the school counselors and express their expectations and concerns. In light of school counselors’ recommendations for enhancing activities to better prepare counseling students for the duties and roles of future school counselors and to contribute to professional identity development, revising school counseling internship programs should be considered.
Limitations and Future Research Directions
Interviews with professional counselors and document data from counseling internship students, classroom guidance teachers and school students who attended group activities were used in this study. Although the triangulation method was used, collection of data from multiple participants was limited since this study was conducted by only one researcher. In the future, if more than one researcher were involved in a study, it would be possible to collect data from a greater number of school counselors, counseling interns, school students participating in group or classroom guidance activities, and teachers at schools. There also was the limitation of not involving a university supervisor in the study. If this level of university supervisor could be involved in a similar study, it would be possible to explore the issue from the different perspectives of relevant parties. Similar studies might be conducted by including counselor education programs from several different universities.
This study showed that school counseling internship programs provide opportunities for counseling students to experience many school counselor activities and to become competent in carrying out these activities. It is clear that school counseling internship programs and activities give counseling students a chance to apply counseling skills, make contributions to students attending counseling activities, lessen the workloads of school counselors, provide proactive counseling services to many more students and contribute to their own professional development. Furthermore, once again it evident that positive and constructive feedback and advice, along with help from university supervisors and site supervisors, were fundamental for counseling interns in conducting activities, feeling positive emotions and establishing confidence.
Conflict of Interest and Funding Disclosure
The author reported no conflict of
interest or funding contributions for
the development of this manuscript.
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Meral Atici is an Associate Professor at Çukurova University. Correspondence can be addressed to Meral Atici, Çukurova University, Education Faculty, 01330, Balcalı, Adana, Turkey, firstname.lastname@example.org