Silent Suffering: Children with Selective Mutism

Sep 5, 2014 | Article, Volume 1 - Issue 1

Lisa Camposano

Despite increasing awareness, the childhood disorder of selective mutism is under-researched and commonly misdiagnosed. The purpose of this article is to highlight current issues related to this disorder as well as describe various treatment approaches including behavioral, cognitive-behavioral, psychodynamic, family, and pharmacological interventions. Suggestions for counselors working with children with selective mutism and implications for future research are offered.

Keywords: selective mutism, childhood disorder, children, etiology, treatment approaches

Although early references occurred 125 years ago, very little has been written about selective mutism (Steinhausen, Wachter, Laimbock, & Metzke, 2006). This disorder remained relatively obscure until 2006 when Newsday published an article entitled “Behind a Wall of Silence” that described an eight year-old girl’s struggle with speaking at school. Selective mutism appeared in the news again the following year when it was revealed that Seung-Hui Cho, the shooter in the Virginia Tech massacre, was diagnosed with selective mutism as an adolescent (Kearney & Vecchio, 2007). Despite media coverage and growing public awareness, little research is being dedicated to examining this unique condition.

The lack of quality research and general awareness of selective mutism are serious barriers to helping children who suffer from this disorder. Too often, these children are misdiagnosed or labeled as “just shy.” Schwartz, Freedy, and Sheridan (2006) surveyed 27 parents having a total of 33 children with selective mutism. Their survey revealed that primary care physicians either misdiagnosed or never referred about 70% of these children. The authors explained: “Selective mutism has largely gone unnoticed by most physicians who are not familiar with the key signs and symptoms. Pediatricians commonly assume that the patient with selective mutism is simply exhibiting excessive shyness and reassure the parents that it is something the child will outgrow” (pp. 43–44). Within the same group of survey participants, an accurate diagnosis did not occur until an average of nearly a year after the parents expressed concerns to a medical doctor (Schwartz et al., 2006). Within school settings, labels such as autistic, language delayed, defiant, or learning disabled saddle such children with inappropriate or ineffective interventions. In many circumstances, parents simply wait for the child to “outgrow” this disorder, not realizing that the absence of proper treatment can lead to lifelong psychological problems (Shipon-Blum, 2007).

The purpose of this article is to increase awareness about selective mutism as well as provide an overview of current issues associated with this disorder. Major themes related to etiology and current trends in treatment will be addressed. The importance of early intervention and participation of family members and school personnel in the treatment process will be stressed. This article will conclude with suggestions for future research, the counseling profession, and counselor training.

Definition of Selective Mutism and Prevalence

Selective mutism is described as “persistent failure to speak in specific social situations (e.g., school, with playmates) where speaking is expected, despite speaking in other situations” (American Psychiatric Association, 2000, p. 125). Children with selective mutism often engage, interact, and communicate verbally within comfortable surroundings, such as at home or with trusted peers. These children are capable of speaking and understand their native language. However, when placed in structured social settings such as school, they are mute and socially withdrawn (American Psychiatric Association, 2000).

Social skills among children affected by selective mutism vary greatly (Amir, 2005). These children are usually unable to verbally communicate when approached by an adult, yet social interaction among peers can vary. Some children interact easily with peers in and outside of the home. Other children interact with peers, but do not verbally communicate with them. A third group remains completely withdrawn in social settings (Amir, 2005). Aside from verbal communication, many children with selective mutism are inhibited in other ways as well (McHolm, Cunningham, & Vanier, 2005). Avoidance of eye contact, lack of smiling, tantrums, blushing, and fidgeting are common symptoms associated with selective mutism (Dummit et al., 1997; Kristensen, 2001; Shipon-Blum, 2007).

Recent studies suggest that selective mutism may occur in .7 to 2% of early elementary students, although many researchers agree that these prevalence rates may be underrepresented due to the lack of knowledge of the disorder (Cunningham, McHolm, & Boyle, 2006; Lescano, 2008; Schwartz et al., 2006; Sharkey, McNicholas, Barry, Begley, & Ahern, 2007). Most investigators report that selective mutism seems to occur more frequently among girls (Cohan, Chavira, & Stein, 2006; Dummit et al, 1997; Lescano, 2008; Mendlowitz & Monga, 2007; Sharkey et al., 2007; Steinhausen & Juzi, 1996). Symptoms of selective mutism are usually present by the age of three, but this disorder is frequently not identified until the child enters school where there is an increased expectation to speak within social settings (Cunningham, McHolm, & Boyle, 2006; Sharkey & McNicholas, 2008). Entrance into the school environment appears to be a salient and definitive landmark for children with selective mutism.

Etiology

There is little consensus regarding the etiology of selective mutism. Psychoanalysts have cited unresolved internal conflicts as the cause of selective mutism (Cohen et al., 2006). Family systems theorists argue that children with selective mutism are part of faulty family relationships (Anstendig, 1998). Kratochwill (1981) states that behavioral therapists “have perceived mute behavior as a function of antecedent and consequent environmental events that vary across situation, people, and time” (p. 137). Early theorists argued that trauma or major life events, such as abuse or the death of a loved one, trigger the onset of selective mutism (Dow, Sonies, Scheib, Moss, & Leonard, 1995). However, according to more recent studies, children who have experienced trauma are not more likely to develop selective mutism, and early childhood trauma is rarely associated with the development of the disorder (Gray et al., 2002; Steinhausen & Juzi, 1996). In fact, Dummit et al. (1997) found no evidence of trauma among their case study participants. Therefore, isolating a single cause or traumatic event does not appear to be helpful in identifying selective mutism, thereby confusing diagnostic attempts.

Current conceptualizations of selective mutism link the disorder to anxiety, namely social phobia (Cunningham et al., 2006; McHolm et al., 2005; Sharkey & McNicholas, 2008). This particular phobia prohibits children from interacting and communicating within social settings, such as school and birthday parties. McHolm et al. (2005) explain that just as a young child can develop a fear of spiders or heights, for example, children with selective mutism have developed a fear of talking that is further crippled by anxiety.

Research has shown that anxiety disorders generally run in families. With regard to selective mutism, parents of children who have selective mutism are likely to exhibit signs of moderate to severe anxiety (Kristensen & Torgersen, 2001; Schwartz, Freedy & Sheridan, 2006; Shipon-Blum, 2007). Kristensen and Torgerson (2001) regarded selective mutism as a “family phenomenon” after they examined personality traits of parents of children with selective mutism (p. 652). According to their study, parents of selectively mute children were significantly more likely to have a history of shyness or social anxiety as compared to a control group. In a survey conducted by Schwartz et al. (2006), 33% of the participants reported a family member with social anxiety disorder and 12.1% had a family member with selective mutism. Despite the information obtained from the aforementioned case studies, it remains unclear how genetic and environmental factors affect the development of selective mutism among young children.

There also is mixed evidence concerning the association between developmental delays and selective mutism. In a study of 100 children with selective mutism (Steinhausen & Juzi, 1996), 38% of participants had a history of language delays or disorders. In contrast, other studies report no evidence of developmental delays among the participants (Black & Uhde, 1995). Definitive research in this area is lacking, and the link between developmental factors and selective mutism remains unclear.

Although the exact cause of selective mutism is unknown, researchers generally agree that selective mutism does not fall under the realm of speech/language disorders, communication disorders, defiant behavior, or shyness. In a recent article written by Kearney and Vecchio (2007), the researchers point out that “this disorder is not due to a communication disorder such as stuttering and it is not due to a lack of knowledge or comfort with language” because affected children speak well in certain situations (p. 917). A case study conducted by Schwartz et al. (2006) revealed that a very small percentage of children with this disorder have speech and/or language difficulties. Selective mutism is distinctly dissimilar from shyness due to the severity of anxiety and duration of symptoms. Shyness is not paralyzing like selective mutism and the vast majority of children who suffer from selective mutism do not fully overcome their anxiety without formal intervention (Stanley, n.d.). Finally, selective mutism has been described by some as oppositional; however this assumption implies that mutism is a conscious choice. This viewpoint is clearly disputed by recent research on this disorder (e.g., Cunningham et al., 2006; McHolm et al., 2005; Sharkey & McNicholas, 2008). Anxiety appears to be the most likely culprit at the core of this disorder. There is evidence that family history of anxiety often plays a role in the disorder while speech and language problems, along with willful opposition, do not seem to contribute to the development of selective mutism.

Approaches to Treatment

Because the etiology of selective mutism is unclear, there is much disagreement among researchers regarding effective treatment approaches. Additionally, scarce quality research has been dedicated to examining the effectiveness of individual treatment approaches and interventions. As Sharkey et al. (2007) notes: “Despite the very handicapping nature of this disorder and its negative impact on both short- and long-term functioning in children and adolescents, the evidence for effective treatments is sparse and predominantly in the form of single case reports or small series using a variety of techniques” (p. 539).

Although a systematic approach has not yet been developed, there are some common goals among varying treatment programs. An initial goal of treatment is to lower the child’s anxiety and develop healthy coping mechanisms for dealing with anxiety (Shipon-Blum, 2007). Interventions aimed at achieving this goal include relaxation skills, meditation, and breathing techniques. Increasing self-esteem and confidence in social settings is another integral objective of most treatment programs. The last and most evident goal is to increase verbal communication in social settings. As the final stage in the treatment process, increasing verbal communication may take years as well as long-term therapeutic intervention depending on factors such as the duration of the mutism and severity of symptoms.

Psychodynamic Approach

Early treatment approaches for selective mutism were mainly derived from psychodynamic theories. Interventions and techniques from this realm of therapy seemed to be the best fit as selective mutism was historically viewed as a result of unresolved inner conflicts or traumatic events during early childhood years (Kratochwill, 1981). Psychodynamic theorists describe mutism as a defense mechanism which the child utilizes rather than expressing feelings directly towards a parent, most commonly the mother (Cline & Baldwin, 1994). Through this approach, the primary goal of the counselor is not to directly address the mutism, but rather understand its origin (Cohen et al., 2006). This is accomplished by carefully examining the child’s early psychosexual stages of development as well as the mother-child relationship, then eventually addressing the fears directly with the child (Cline & Baldwin, 1994).

There exists a major pitfall in this type of therapeutic approach. Symptoms of this disorder are deeply rooted in anxiety; therefore, pressure to verbalize thoughts and feelings can overwhelm the child. While expression can be accomplished through nonverbal means such as art therapy, substantial conversation and uninhibited free association are extremely difficult to achieve. It is more likely that the child will become tense and freeze up when placed in the structured setting of the counselor’s office and asked to communicate. Shipon-Blum (2007) explains that psychological approaches are effective only when “all pressure for verbalization is removed and emphasis is [placed] on helping the child relax and open up” (p. 6). When pressure to verbalize is reduced, anxiety decreases and therapeutic interventions can subsequently occur.

In 1963, Browne, Wilson, and Laybourne (as cited in Garcia, Freeman, Francis, Miller, & Leonard, 2004) examined the effectiveness of psychodynamic therapy for selective mutism and concluded that the treatment was costly and commonly yielded a poor outcome. Freeman, Garcia, Miller, Dow, and Leonard (2004) added that there are no major case studies or research to provide evidence that these approaches are successful. While psychotherapy is rarely utilized as a primary mode of treatment for selective mutism today, psychodynamic projective interventions such as play, music, and art therapy are commonly utilized by counselors in conjunction with other treatment approaches. Research has shown that these projective, less verbal interventions have been effective to some degree (Shreeve, 1991; Tatem & DelCampo, 1995).

Play therapy can offer a safe environment in which the counseling relationship is established without placing pressure on the child to speak (Hultquist, 1995). While describing the benefits of using psychotherapy with anxious children, Terr (2008) claims that effective therapy for anxiety disorders such as selective mutism “won’t truly begin until [the spirit of play] is established” (p. 101). Additionally, music therapy can assist children with selective mutism to express their thoughts or feelings via nonverbal means as well as reduce anxiety through musical expression. Amir (2005), the director of a music therapy program at an Israeli university, describes her two-year experience of working with a selectively mute child. She concluded that the therapy sessions encouraged “feelings of safety” and served as “a container and foundation where heavy feelings and emotions [could] be explored” (p. 75). Furthermore, Amir claims that a trained music therapist can interpret music created by the child in order to establish a bridge to the child’s “inner world” (p. 76). Similar to music therapy, art therapy provides a mute child with a nonverbal way to articulate feelings and fears. Cline and Baldwin (1994) noted that art therapy provides a “springboard for verbal communication” (p. 80). While these interventions are not generally used as primary modes of treatment, play, music, and art therapy can improve self-esteem and provide the counselor with an opportunity to build rapport and create a safe, inviting environment for the child.

Behavioral Approach

Researchers from the behavioral perspective view selective mutism as a learned behavior developed as a coping mechanism for anxiety. Therefore, the purpose of treatment is to decrease anxiety and increase verbal communication in settings such as school (Cohan et al., 2006). This approach incorporates practice and reinforcement for speaking in subtle and non-threatening ways. Emphasis is placed on observable behavior rather than early childhood development (McHolm et al., 2005).

Behaviorists rely on various techniques, such as shaping, self-modeling, and contingency management, to increase verbal communication and lower anxiety. Shaping, sometimes referred to as a ritual sound approach, is the procedure in which the counselor reinforces mouth movements and sounds that resemble speech (Mendlowitz & Monga, 2007; Shipon-Blum, 2010). This strategy involves breaking down the target goal of verbal communication into smaller steps in order to minimize anxiety. The exact sequence will vary according to the child, but some steps may include mouthing words, making sounds, whispering, repeating a word the counselor has said, and eventually increasing volume of speech (Cline & Baldwin, 1994; Lescano, 2008).

Another commonly-used strategy to elicit speech is a two-part process known as self-modeling. Using an audio or video recorder, the child speaks and answers questions within a comfortable environment. The tape is then edited to portray the child speaking in settings such as school. The child listens to the tapes repeatedly, often in the company of family members or friends, in order to become accustomed to hearing him/herself speak in these settings (Blum, Kell, & Starr, 1998). A variation of this strategy may include family members who are recorded while asking questions such as those the child might hear in school (Cline & Baldwin, 1994). The child then practices giving oral answers. Case reports (e.g., Kehle & Owen, 1990; Pigott & Gonzales, 1987) have noted successful treatment outcomes after utilizing this strategy with selectively mute clients. This technique is frequently used in many behavioral and eclectic treatment approaches, but Blum, Kell, and Starr (1998) note that taping can increase anxiety and may not be suitable for all clients.

Contingency management refers to the use of positive reinforcement as encouragement for the child to practice verbalizations. As early as the 1930’s, Skinner (1938, 1971, as cited in Neukrug, 2007, p. 101) showed that specific behaviors would be repeated if positive reinforcement were given as soon as the behavior occurred. Contingency management is often used in conjunction with systematic desensitization in which the counselor sets goals of increasing difficulty with corresponding rewards for each leveled task that is completed (Lescano, 2008). This hierarchy of tasks is created with a consideration of locations, activities, and people that affect the child’s comfort level (McHolm et al., 2005). Similar to systematic desensitization, stimulus fading is commonly used to gradually increase the number of people in the room or classroom as the child practices verbalizations. Positive reinforcement often accompanies treatments involving stimulus fading.

While psychodynamic approaches were formally the treatment of choice by many counselors and researchers, behavioral interventions are currently included in most treatment programs for selective mutism. This type of treatment provides a step-by-step approach that can be easily modified to fit the changing needs of the child. Behavioral techniques, such as shaping and self-modeling, are rarely used in isolation so it is difficult to assess the effectiveness of any single strategy. As a complete entity, behavioral treatment has been carefully researched and numerous studies have shown efficacious outcomes of this type of treatment (e.g., Gray et al., 2002; Kehle & Owen, 1990; Lescano, 2008).

Cognitive-Behavioral Approach

While the success of behavioral interventions is rarely disputed, the behavioral approach to therapy does not place emphasis on an individual’s anxious thoughts. Some researchers consider this a major flaw and stress the importance of restructuring thought processes. The cognitive-behavioral approach to treatment, or CBT, is a practical, action-based treatment program that incorporates many of the aforementioned behavioral techniques such as systematic desensitization and stimulus fading. However, CBT is different from behavioral approaches because it has an additional dimension that stresses anxiety management education (Chansky, 2004). Chansky (2004) explains that during CBT, both children and parents develop “a specific set of skills to address the thoughts, physiological responses, and behaviors associated with anxiety” (p. 47). Treatment also requires children to use problem-solving and employ self-talk (McHolm et al., 2005). The ultimate goal of CBT is to help children modify their behavior by assisting them in redirecting their anxious fears and worries in healthy ways (Shipon-Blum, 2007).

Cognitive-behavioral treatment includes several components in addition to behavioral techniques. An important aspect of CBT is assessment. Many early sessions are solely dedicated to identifying factors that contribute to the child’s anxiety (Chansky, 2004). The information obtained in these interviews guides treatment and provides a foundation when planning therapeutic activities. Shipon-Blum (2002), for example, has developed a continuum for ongoing assessment that ranges from non-communicative to initiating verbal communication, with many stages of nonverbal and verbal communication in between. This continuum is used to assess a child’s level of anxiety within different settings as well as to set and modify goals for treatment. Since levels of anxiety are likely to elevate during behavioral interventions, particularly systematic desensitization and stimulus fading, children are taught relaxation skills in order to manage anxiety before applying such techniques (Cohan et al., 2006). These skills may include breathing techniques, muscle relaxation, or story telling (Sharkey & McNicholas, 2008).

Once research linked selective mutism to anxiety, evidence-based CBT interventions that were previously used to treat other anxiety disorders in children and adolescents were commonly incorporated in the treatment of selective mutism (Mendlowitz & Monga, 2007). One of these interventions, cognitive restructuring, has been utilized to call attention to and minimize negative or anxiety-producing automatic thoughts (Chansky, 2004). In its conventional form, this type of intervention requires the client to share and express feelings to the counselor. This clearly presents an obstacle when working with children who are selectively mute and are not comfortable talking in certain situations, such as a counselor’s office (McHolm et al., 2005). If a child can be expressive using nonverbal means, or if a child is comfortable enough to speak to the counselor, cognitive restructuring can assist a child in learning to cope by thinking realistically. It is important to mention that a child’s cognitive development dictates how well this intervention may work. Therefore, this intervention may be most effective with older children having average to above-average intelligence and the ability to think flexibly and in abstract ways. Despite these limitations, cognitive restructuring is an important element in the treatment process for some children.

Cognitive-behavioral treatment has gained attention from researchers of this disorder. Recent case studies and reviews (e.g., Cohan et al., 2006; Mendlowitz & Monga, 2007; Schwartz et al., 2006; Woodcock, Milic, & Johnson, 2007) have demonstrated the success of CBT in treating children suffering from selective mutism. Additionally, the safe nature of this type of treatment along with its high success rates, make it popular. Perhaps its most significant drawback is the amount of time and patience required of the counselor. Mendlowitz and Monga (2007) estimated that children suffering from selective mutism require five to six times more CBT intervention sessions than children suffering from generalized anxiety or separation anxiety.

Pharmacological Approach

Sometimes a child’s symptoms are so debilitating that fully engaging in a counseling treatment program seems challenging. In such cases, researchers may initially utilize pharmacological interventions to assist the child in overcoming anxiety associated with the disorder so that other treatments can subsequently occur. This type of intervention may include selective serotonin reuptake inhibitors (SSRIs) or monoamine oxidase inhibitors (MAOIs) (Kearney & Vecchio, 2007). While pharmacotherapy is not generally recommended as the primary treatment, the use of medication can often facilitate CBT or other interventions (Kumpulainen, 2002). Once anxiety levels have been reduced via medication, verbal communication may become less challenging for the child.

The effectiveness of pharmacological interventions is perhaps one of the most widely debated issues related to this disorder. Shipon-Blum (2007) deems a combination of behavioral techniques and medication the best approach to treating selective mutism, while Black and Uhde (1995) noted that the differences between pharmacologically treated and non-treated groups were mostly insignificant. Kumpulainen (2002) reported that pharmacological interventions could be helpful when treating selectively mute children, but also warns that medication should be used in conjunction with other therapy modalities only when they are not independently successful. It is important to note that the short- and long-term effects of pharmacotherapy remain unclear. While Kumpulainen (2002) reported that participants seldom reported any harmful effects of the medication, Kearney and Vecchio (2007) admit that there are no large-scale studies of pharmacotherapy for selective mutism.

Family Counseling/Therapy

Family counseling or therapy is often a necessary component of an effective treatment plan for children with selective mutism. Meyers (1984) noted dysfunction within the families of children with selective mutism. Other studies have cited higher rates of marital conflict and divorce among families of children with selective mutism when compared to controls (Viana, Beidel, & Rabian, 2009). Researchers from the family systems perspective have hypothesized that a child’s mutism serves a certain function within the family (Anstendig, 1998). Therefore, it may be beneficial for all members of the family to participate in counseling in order to resolve underlying family issues that may have maintained the mutism. In general, the goal of family intervention in relation to selective mutism is to identify faulty family relationships and communication patterns that may have contributed to the development of the child’s anxiety. The counselor would subsequently aim to help family members remove conditions that are causing the child’s anxiety and maintaining the mutism (Cohan et al., 2006).

While research concerning the effectiveness of family counseling is scarce, it is evident that the cooperation and participation of parents in the treatment has a positive impact on recovery (e.g., Kumpulainen, 2002; Mendlowitz & Monga, 2007; Sharkey et al., 2007). In fact, Sharkey and McNicholas (2008) deemed parental involvement as the “key ingredient in treatment success” (p. 544). Acceptance and understanding of the disorder is crucial, and parents should not place emphasis on the lack of verbal communication. Shipon-Blum (2007) emphasizes the importance of parent participation during the treatment process: “Praise should be given for the child’s accomplishments and efforts, and support and acknowledgement should be given for their difficulties and frustrations” (p. 5). Treatment programs often require parents to modify their parenting styles as well as develop healthy coping skills for handling stress and fear. Anxiety management education is often integrated with treatment so that parents are equipped to model healthy coping abilities for their children (Mendlowitz & Monga, 2007).

Counselors also may encourage parents to consider the amount of attention that is given to the child’s nonverbal behavior (Beidel & Turner, 1998). A child’s lack of verbal responses can result in a sibling or parent consistently answering for the child or overcompensating by frequently calling attention to the child’s strengths or talents. In a case study by Sharkey et al. (2008), researchers trained parents to ignore their child’s mutism and reinforce verbal behaviors by consistently responding to these behaviors with empathy, enthusiasm, and warmth. Shifting attention to verbal behaviors rather than nonverbal behaviors provides positive reinforcement for such actions.

Multifaceted Approaches

Due to the complex nature of this disorder, there exists strong support for treatment programs for selective mutism to be multifaceted, address anxiety in a variety of settings, and involve teachers, peers, parents, and other family members during the treatment process. Therefore, an eclectic approach is the most common treatment option currently used by counselors. Countless researchers have successfully combined psychodynamic, behavioral, cognitive-behavioral, pharmacological, and/or family counseling interventions. An example of a successful eclectic treatment approach was described by Wright, Cuccaro, Leonhardt, Kendall, and Anderson (1995) in a preschool-aged child. This treatment included behavioral interventions, play therapy, family therapy, and pharmacotherapy. Jackson, Allen, Boothe, Nava, and Coates (2005) also used a multifaceted approach consisting of shaping, systematic desensitization, play therapy, parent journaling, and relaxation training to successfully treat a six-year-old boy with selective mutism. While this type of treatment approach has consistently appeared to be effective in published case studies, more research is needed to reveal which components of these programs are essential.

Importance of Early Diagnosis and Intervention

Early, accurate diagnosis and intervention are crucial to overcoming selective mutism regardless of the type of treatment program. Research suggests that treatment for this disorder is most effective if it begins as soon as symptoms of the disorder become apparent, thus minimizing the amount of negative reinforcement for these behaviors (e.g., Schwartz et al., 2006; Stone & Kratochwill, 2002). Shipon-Blum (2007) explains: “The earlier a child is treated for selective mutism, the quicker the response to treatment and the better the overall prognosis. If a child remains mute for many years, his or her behavior can become a conditioned response where the child literally becomes accustomed to nonverbalization as a way of life” (p. 5).

Shipon-Blum (2007) warns that if selective mutism is left untreated, the academic, social, and emotional repercussions may include depression, social isolation, poor academic performance, self-medication with drugs and alcohol, and suicide. Furthermore, Chansky (2004) points out that untreated anxiety associated with selective mutism also can lead to adverse health effects including cardiac, immune, and respiratory problems. Thus, early intervention provides more opportunity for successful treatment and, in the long term, a healthier, more functional child.

Role of School Personnel in Treatment

School personnel, especially teachers, play crucial roles in the treatment of selective mutism. Because the symptoms of this disorder are more evident once the child begins school, teachers often become responsible for making a referral for diagnosis. Most school personnel do not have the expertise or experience to deal with this disorder single-handedly, but it is important that teachers recognize anxious tendencies among these children and solicit the help of a school psychologist or counselor in order to make prompt referrals. Once an accurate diagnosis is made, studies (e.g., Kumpulainen, 2002; Lescano, 2008; McHolm et al., 2005) have shown that the willingness of the teacher and other school personnel to collaborate with the parent(s) and counselor affects the outcome of the treatment program. A multidisciplinary team that includes the child’s teacher, principal, school counselor, and/or school psychologist may collaborate with the parent and contribute observations and feedback to the counselor (Lescano, 2008; McHolm et al., 2005). Vecchio and Kearney (2007) indicated that this team approach may be helpful in treatment “because of the widespread nature of the child’s [speech] avoidance” (p 41).

Teachers may assist in reinforcing behavioral treatment techniques as well. For example, a teacher may provide positive reinforcement for verbalizations in school or participate in a video recording which the child will use to practice formulating verbal responses to questions. The teacher also may help to minimize anxiety while the child is in school. Shipon-Blum (2003) emphasizes the importance of a caring classroom teacher who understands the behavioral characteristics of the disorder and allows the child to communicate by nonverbal means as long as necessary. A nurturing, comforting classroom environment and flexibility within the classroom setting and schedule also are important factors in a multifaceted treatment program (Shipon-Blum, 2003). Overall research, therefore, supports both an individual and systematic approach that includes school personnel for the treatment of selective mutism.

Summary and Commentary

As described in this article, selective mutism is a complex psychological disorder with an unknown origin. There is general agreement that selective mutism is characterized by a child’s inability to speak in certain social settings despite the ability to speak in other situations. Nonetheless, there is disagreement among researchers regarding the most efficient and definitive treatment approach. Treatment has included a variety of psychodynamic, behavioral, cognitive-behavioral, pharmacological, and family systems methods. It seems that these approaches are rarely used in isolation; rather treatment programs for selective mutism are usually multifaceted. The cooperation of parents and school personnel during treatment is crucial for positive outcomes, and early intervention can minimize the long-term psychological effects (Kumpulainen, 2002; Shipon-Blum, 2007).

Suggestions for Counselors

While the main purpose of this article is to raise awareness of this disorder and its varying treatment options, counselors who are treating children with selective mutism should prioritize goals during treatment. Less emphasis should be placed on the absence of verbal communication, especially during the initial stages of counseling. An immediate goal is to build rapport and a trusting counseling relationship with the child. Once rapport is established, anxiety reduction is a vital component of any treatment plan for selective mutism. Behavioral strategies, such as stimulus fading and systematic desensitization, that are implemented before healthy coping skills are established will likely increase a child’s anxiety and delay further treatment. In addition, it is important that the counselor and parent(s) work together to build the child’s self-esteem and confidence, especially in social settings. Once anxiety levels are lowered and a child’s confidence is established, verbal communication interventions will likely follow.

Additionally, it is vital that counselors design multifaceted therapy programs when treating children with selective mutism. Due to the complex nature of this disorder, eclectic treatment addresses varying symptoms and psychological effects caused by selective mutism. A multidisciplinary team should be established to assist the child in treatment. As discussed earlier, school personnel play an important role on this treatment team since the child’s mutism is likely to be most apparent at school. These professionals may aid the counselor by providing regular monitoring of progress and implementation of behavioral interventions.

Lastly, it is important that a counselor take into consideration the amount of time and patience required to implement a treatment program for selective mutism. A thorough and detailed assessment is first required to determine factors affecting the child’s mutism. Jackson et al. (2005) recognized “an in-depth analysis of the client and his or her environment” as a precursor for treatment (p. 107). After the initial stages of treatment and assessment, it is anticipated that the counselor will spend a considerable amount of time working outside of the office (Vecchio & Kearney, 2007). The counselor may conduct observations at the child’s school, meet with the child’s teacher and school counselor, and interact with the child in various social settings in order to effectively monitor and adjust treatment goals and implement appropriate interventions. If the counselor is unwilling or unable to devote such a level of time and dedication, a referral to another counseling professional with knowledge of this disorder should be provided to the client.

Suggestions for Future Research

Selective mutism has gained considerable national and global attention, particularly due to several magazine and professional articles recently published about this disorder. As a result, awareness is increasing while quality research on this serious disorder is scarce. Evidence for effective treatment has been predominantly presented in the form of single-case studies using a variety of techniques. Within these studies, the duration of treatment and follow-up time is brief and the age range is narrow, usually addressing only the needs of younger elementary school children (Cohan et al., 2006). In order to better understand selective mutism and the treatment approaches that best minimize its associated symptoms, it is imperative that large-scale studies are conducted with a focus on the efficacy of isolated techniques.

Beare, Torgerson, and Creviston (2008) described interventions used to increase the verbal behavior of a 12-year-old boy with selective mutism. These researchers exclusively utilized positive reinforcement to successfully increase verbalizations in three different settings. This is the only known case study where a single intervention was isolated and its effectiveness examined. It is important to note that case studies have limitations, involve a limited number of participants, and often lack control groups, as did this study. Despite such limitations, this study provides a springboard for further research on isolated interventions and will hopefully precipitate large-scale research devoted to examining effective treatment interventions for selective mutism.

In addition, research should be specifically devoted to examining the impact selective mutism has on long-term social development. It is logical to expect some level of social maladjustment regarding development of social relationships with peers given that children with selective mutism have limited social interactions. This is supported by research that has linked anxiety disorders, specifically social phobias, with social withdrawal and other difficulties regarding sociability (Beidel, Morris, & Turner, 2004). Nonetheless, case studies (e.g., Cunningham et al, 2004; Kumpulainen, 1998; Pelligrini, Bartini, & Brooks, 1999) imply that children with selective mutism are not bullied or victimized more than children who do not have selective mutism. More research is needed in this area to determine the extent of social maladjustment among children with selective mutism. Additionally, research should be devoted to investigate long-term effects of this disorder after the mutism is overcome. For example, exploring the ability to form relationships during teenage and adult years may help clarify the impact of mutism on long-term social development.

While an increasing amount of literature on selective mutism has been published during the last fifteen years, studies involving school personnel are virtually nonexistent. Children with selective mutism spend several hours each day with school professionals who are often involved in treatment interventions. More importantly, school is frequently the setting in which these children have the highest level of anxiety and mutism. Research has shown that teachers’ involvement in the treatment process is vital to positive treatment outcomes (e.g., Kumpulainen, 2002; Lescano, 2008), yet their role in the treatment process is rarely described in the research. There is an urgent need to carefully examine these children’s behaviors and interactions in the classroom during treatment, as well as interventions performed by the teacher. Such information would be vital to determining the overall effectiveness of treatment programs, specifically within the school setting.

Suggestions for Counselor Training

In addition to the recommendations pertaining to research and the counseling profession, it is important that counselor education provide training for treating this disorder. It is imperative that counselors, especially school counselors or counselors working with children, be trained in identifying the signs and symptoms of selective mutism. This training should stress that selective mutism be treated as an anxiety disorder, and the difference between this disorder and shyness, autism, or speech/language disorders should be emphasized. Additionally, instruction on non-verbal assessment tools should be provided as this is an ongoing aspect of treatment. Finally, counselors should be trained to work cooperatively with school personnel and parents when treating children with anxiety-related disorders, including selective mutism, because empathetic and knowledgeable school personnel are assets to successful treatment programs.

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Lisa Camposano is a fourth grade teacher at Millstone Township Elementary School, Millstone Township, NJ, and a graduate student in the CACREP-accredited program in School Counseling at The College of New Jersey, Ewing, NJ. The author thanks Dr. Mark Kiselica, The College of New Jersey, for his mentorship and encouragement throughout the writing process. The author also thanks the Sciscente family (with permission) for the inspiration to write this article. Correspondence can be addressed to Lisa Camposano, 308 Millstone Rd, Millstone, NJ, 08510,
LisaCamposano@yahoo.com.

A Preliminary Exploration of Support Systems for Parents of Children with Special Needs

Sep 3, 2014 | Article, Volume 1 - Issue 1

Chiharu Hensley

Raising a child with special needs exacerbates the inherent challenges of parenting. Although the needs of children with special needs are addressed frequently in the literature, the needs of the parents of children with special needs are often neglected. In order to offer effective and useful services for parents of children with special needs, this article examines the types and nature of support services used by the parents of children with special needs and the effectiveness of those support services in reducing the parents’ stress levels and/or increasing their coping skills. Seventy-four parents of special needs children were assessed and results revealed that low-cost services, particularly those that resulted in mutual support, were a significant priority among parents. The article concludes with a discussion of clinical implications and needed directions for future research.

Keywords: parenting, children, special needs, support services, counseling

Parenting involves much effort and countless responsibilities. Child rearing can be one of the most challenging tasks with which a person is confronted. Raising a child with special needs intensifies the challenge significantly. However, although the needs of children with special needs are addressed frequently in professional literature and in the media, the needs of parents of children with special needs are addressed far less often. In order to offer effective and useful services for parents of children with special needs, their experiences with common issues and concerns and how their needs can be met must be investigated and understood because such information is essential to enable parents to feel empowered in raising their children with special needs.

Parents of children with special needs often experience high levels of stress from both internal and external factors. For example, a study conducted by Heiman (2002) revealed that 84.4% of the participants who had children with various special needs experienced feelings including “depression, anger, shock, denial, fear, self-blame, guilt, sorrow, grief, confusion, despair, [and/or] hostility” at the time of their children’s first diagnoses. Barnett, Kaplan-Estrin, and Fialka (2003) reported a study of parents of children who were mildly or moderately impaired that showed about half of the parents were still experiencing negative responses to their children’s diagnoses two or more years after the initial diagnosis.

In addition, parents of children with special needs may suffer being stereotyped by others. For example, Goddard, Lehr, and Lapadat (2000) used focus groups to collect individual narratives from parents of children with special needs. They found that, more than the parents’ guilt or the condition of the child, being perceived as a victim of a tragedy and the sole advocate for the child as well as a lack of understanding from others, including professionals, contributes to parental stress. Financial concern is another external factor which contributes to high stress levels in parents raising children with special needs. Looman, O’Conner-Von, Ferski, and Hildenbrand (2009) found that the severity of a child’s special needs increased the odds of financial burden experienced by the family. Clearly, there are a variety of both internal and external stressors, and accompanying emotional reactions, with which parents of children with special needs are confronted. Therefore, providing services to reduce the stress and negative feelings to minimum levels would lead to better quality of life for the parents of children with special needs.

Given the relative lack of attention to the support service needs of parents raising children with special needs, the purpose of this study was to conduct an exploratory investigation of the types of services used by parents of children with special needs and the effectiveness of those services for reducing parents’ stress levels and increasing their coping skills.
Four primary research questions were addressed in this study:
1. What are the types of services used by parents of children with special needs?
2. How effective are services in reducing stress levels of such parents?
3. How effective are services in increasing the coping skills of parents?
4. What are some of the needs of parents which may be met by counseling services?

Method

There were two major parts to this research. The first involved distribution of a survey to parents of children with special needs and the second involved an extensive interview with a representative parent of a child with special needs. In the first part of the study a survey was used to collect data for approximately one year. Potential respondents included parents and/or primary caregivers of preschool or school-age children with special needs who resided in a Midwestern state. No restriction was placed on the potential respondents based on the type or number of special needs their child had. Participants were recruited through contact with organizations for families of children with special needs (e.g., local associations for learning disabilities, pervasive developmental disabilities, and physical disabilities) and snowball sampling with assistance of professionals at local public schools who work with children with special needs and their parents. An online survey, the primary means of data collection, was created using a commercial website (www.surveymonkey.com), and potential respondents were directed to the survey webpage from either the websites of the organizations or by typing in the website address found on a distributed survey invitation flyer. A paper version of the survey was prepared for participants from a university clinic for speech and hearing.

The second part of the study involved an individual follow-up interview. Initially, the intent was to garner enough participants for a focus group activity. Unfortunately, however, of all the survey respondents, only one expressed interest in participating in a focus group. Therefore, this respondent was selected and interviewed in order to explore the stressors, challenges, and supports available for the parents in greater depth. The interview was audio-taped and transcribed by the investigator.

Results

There were a total of 74 respondents. Among the respondents, 70 (94.6%) completed the survey online and 4 (5.4%) completed the paper form of the survey. Selected survey items and the resultant data are shown in Table 1.

Table 1

Selected Survey Items and the Resultant Data

Survey Items No. of Responses % Responses

Items for all the respondents (N = 74)
How would you rate your degree of stress on the following scale?
In the last month?
Very low 0 0.0
Low 8 10.8
Moderate 22 29.7
High 33 44.6
Very High 9 12.2

In the last year?
Very low 0 0.0
Low 5 6.8
Moderate 23 31.1
High 24 32.4
Very High 21 28.4

What would be the ratio of each factor that might be contributing to your stress level?

Raising a child(ren) with special needs
About 1–25% 9 12.2
About 26–40% 15 20.3
About 41–60% 15 20.3
About 61–80% 23 31.1
About 81–100% 11 14.9

Financial concerns
About 1–25% 15 20.3
About 26–40% 20 27.0
About 41–60% 12 16.2
About 61–80% 7 9.5
About 81–100% 15 20.3

Have you sought professional services (i.e., therapies) in dealing with your stress of raising a child(ren) with special needs?
Yes 30 40.5
No 43 58.1

If you answered No to the previous question, what was (were) your reason(s) for not seeking professional services (i.e., therapies)? (n = 43)

Unable to afford the service 5 11.6
Schedule conflict 7 16.3
Did not know about any service available 7 16.3
Unable to find a service that seemed
helpful for your needs 12 27.9

Counseling as a category of received service (n=30)

Type of service you have received:
Individual counseling 22 73.3
Couples counseling 3 10.0
Family counseling 7 23.3

How helpful was the service for dealing with your stress?
Very helpful 7 23.3
Somewhat helpful 12 40.0
Neutral 2 6.7
Somewhat unhelpful 2 6.7
Very unhelpful 3 10.0

Compared with your stress level before receiving service, how much has it changed after
receiving service?
Not changed at all 2 6.7
Greatly reduced 12 40.0
Somewhat reduced 7 23.3
Unsure 2 6.7
Somewhat increased 2 6.7
Greatly increased 2 6.7

Compared with your outlook on raising your child(ren) with special needs before receiving service, how much has it changed after receiving service?
Not changed at all 3 10.0
Greatly more optimistic 12 40.0
Somewhat more optimistic 4 13.3
Unsure 6 20.0
Somewhat more pessimistic 1 3.3
Greatly pessimistic 0 0.0

Group as a category of received service (n=16)

Group counseling 2 12.5
Support group 14 87.5

How helpful was the service for dealing with your stress?
Very helpful 6 37.5
Somewhat helpful 8 50.0
Neutral 1 6.3
Somewhat unhelpful 0 0.0
Very unhelpful 1 6.3

Compared with your stress level before receiving service, how much has it changed after receiving service?
Not changed at all 0 0.0
Greatly reduced 10 62.5
Somewhat reduced 3 18.8
Unsure 1 6.3
Somewhat increased 2 12.5
Greatly increased 0 0.0

Compared with your outlook on raising your child(ren) with special needs before receiving service, how much has it changed after receiving service?
Not changed at all 1 6.3
Greatly more optimistic 8 50.0
Somewhat more optimistic 2 12.5
Unsure 3 18.8
Somewhat more pessimistic 1 6.3
Greatly more pessimistic 0 0.0

Items for the respondents who sought a professional service(s) in the past for dealing
with their stress of raising their children with special needs (n=30)

What have you gained from receiving service(s)?
Peer support 8 26.7
Professional support 7 23.3
Network 10 33.3
Specific knowledge about the
child(ren)’s disability(ies) 14 46.7
Specific skills for dealing with
the child(ren)’s needs 13 43.3

What are some of the factors that you consider when choosing a service?
Cost (including transportation
and session fees) 20 66.7
Schedule/frequency 21 70.0
Format (e.g., individual vs. group vs.
psychoeducational vs. counseling) 16 53.3

How likely are you to seek an additional service(s) in the future?
Very likely 9 30.0
Likely 8 26.7
Unsure 6 20.0
Unlikely 1 3.3
Very unlikely 0 0.0

If you were to receive an additional service(s), what would be the most likely format/venue?
Individual counseling 15 50.0
Couples counseling 4 13.3
Family counseling 8 26.7
Group counseling 1 3.3
Support group 13 43.3
Parenting training individual sessions 4 13.3
Parenting training group sessions 6 20.0
Individual psychoeducational sessions 0 0.0
Psychoeducational group sessions 3 10.0
Coping skills—individual sessions 5 16.7
Coping skills—group sessions 3 10.0
Stress management—individual sessions 8 26.7
Stress management—group sessions 4 13.3

Note. Some of the items allowed multiple answers by a single respondent. Percentage of respondents for each item was measured based on the number of respondents corresponding to specific items.

Some of the 74 respondents did not provide responses for all items. The respondent group included 67 females (90.5%) and 63 (85.1%) participants who identified themselves as Caucasian/White. Thirty-five respondents (47.3%) were between ages 31 and 40, and 58 (78.4%) were married. Fifty-nine of the respondents (79.7%) had one child with special needs and 31 (41.9 %) reported the child’s disability as moderate.

In regard to stress levels, 33 respondents (44.6%) indicated that they had experienced a high degree of stress in the past month, and 45 (60.8%) indicated that they had experienced either a high or very high degree of stress in the past year. Twenty-three respondents (31.1%) indicated that raising their child with special needs contributed to about 61–80% of their total stress level, and 20 (27.0%) indicated that their financial concerns contributed to about 26–40% of their total stress level. In regard to help seeking, 45 (60.8%) indicated that they had never sought professional services (e.g., various possible therapies) to cope with the stress of raising a child with special needs. The most frequently cited (n = 12, 27.9%) reason for not seeking support services was that they were unable to find services that they perceived to be helpful for their needs.

Among the 30 respondents who had sought professional services, 22 (73.3%) indicated that they had sought individual counseling (which also was the most used type of service). The second most used type of service was support groups, in which 14 respondents (46.7%) indicated that they had joined or were current members of a support group. Among those who had received individual, couple, family, or any combination of counseling, 19 (73.1%) indicated that their stress levels were reduced to some or a great extent after receiving such service(s) and 16 (61.6%) responded that their outlook on raising their child with special needs became somewhat or greatly more optimistic.

Specifically, among the 16 (53.3%) who had received either group counseling, participated in support groups, or both, 13 (81.3%) indicated that their stress levels were somewhat or greatly reduced and 10 (62.5%) indicated that their outlook on raising their child) with special needs became somewhat or greatly more optimistic. Finally, 14 (46.7%) responded that they had gained specific knowledge about the child’s disability from receiving the services and 13 (43.3%) responded that they had gained specific skills for coping with the child’s needs.

Although the respondents in this latter subgroup had participated in a wide variety of support services, it appears that most were psychoeducational in nature. Seventeen respondents (56.7%) also reported that they were either likely or very likely to seek additional services in the future. The three most selected types of services that these respondents would most likely seek were individual counseling (n=15, 50.0%), support groups (n=13, 43.3%), and family counseling (n=8, 26.7%). Session schedule and frequency, cost (including transportation and session fees), and format of the service were all important factors considered in use of support services.

The second part of the study was an interview with the mother of a son with cerebral palsy in order to gather information about personal experiences, particularly those contributing to her level of stress. The interview was conducted at a house close to the hospital to which she periodically brought her son for treatment. At the time of the interview, Amy (a pseudonym), the mother, was 39 years old, and Michael (a pseudonym), her son, was two years old. Amy was Caucasian, between 31 and 40 years old, married, and had one child with special needs; therefore, she was “typical” of the majority of the respondents to the survey. Specific interview questions were not prepared in advance. Rather, Amy was asked to convey her most important and/or strongest experiences and emotions as a mother of a child with special needs.

A wide variety of issues were discussed during the interview, but the most pressing issue mentioned by Amy was the lack of available resources for parents of children with special needs. Amy related that large cities might have many resources available, “but especially not my little small town—the resources are so limited.” She talked about how in attempting to acquire information and resources to aid in Michael’s care, she had asked many different people. Importantly, she did considerable research on her own, primarily using the Internet. She felt that many, or perhaps most professionals did not know more than she did, regardless of their formal education and training. She gave the example of having told one of Michael’s doctors about Euro-Pēds, a facility specializing in physical therapy for children with cerebral palsy and other neuromuscular disorders. The doctor did not know about this resource. Amy also related how shocked she was when a receptionist at a local mental health facility was not aware of a “respite” fund provided by the facility. She expressed that it was “disheartening that these people are supposed to guide me, and they just couldn’t.” Then she went on to describe a situation in which parents of children with special needs could not obtain the service they wanted because they did not use the technical term:

I was told that there were even situations where people who aren’t articulate would call and say, ‘I need a
babysitter.’ And they say, ‘We don’t do babysitting services.’ Click. Because they didn’t say ‘respite,’ they were turned away…. It’s their job to be in tune with, maybe there’s something I’m not getting here. Let me figure out what’s wrong with this person that’s calling my mental health facility.

Amy was often disappointed in seeking resources and help, probably because of the lack of understanding and education among professionals.

Amy lamented that resources external to the family should not cause more stress because parents of children with special needs already are overwhelmed by feelings of guilt, helplessness and stress. She believed that Michael was not the cause of her issues, but rather that the actual problems were the by-products of his having a disability:

It’s not always directly related to the child, but all the side effects that how they affect you… A lot of it is just the overwhelming feeling that sometimes you wake up in the morning and say, ‘I can’t believe that he has so many problems.’ And you feel sorry for him, and you feel stressed out about it.

Amy also felt guilty about not being able to spend as much time as she would have liked with her other two children; the demands of Michael’s situation dominated all her plans. Amy had tried to be with her other children whenever she could, but still felt that she was not doing enough for them. Thus, she believed that Michael’s disability affected not only her, but also everyone else in the family. Amy also felt tremendous pressure when talking to Michael’s doctors:

Michael’s doctors say, ‘We don’t know if he can ever walk. But we don’t know if he won’t. It’s gonna be up to you, Mom. It’s gonna be, if he’s got the potential to do it. You’re the one that’s gonna push him…’It’s a lot of pressure and I don’t think that these doctors meant to give me that unneeded pressure… But I work very hard to push Michael, you know, everyday. But it scares me. It scares me that, ‘Am I pushing him enough? Am I pushing him too hard?’

Obviously Amy (and other parents of children with special needs like her) suffers from high levels of stress from both internal and external factors. To Amy, taking care of Michael was like “not knowing how to swim and you get thrown into a pool with another person who doesn’t know how to swim.” When Michael was born, Amy had to teach herself how to raise a child with special needs because “these children don’t come with an instruction manual…or a book of resources.” She believed that knowledge about Michael’s disability would be particularly important in order for her to take care of him properly and effectively. She also was aware that the process of accepting her son’s disability and learning how to take care of a child with special needs could be “a nightmare for some people,” because “even someone with formal medical training struggles with these children.” Amy related that she thought a support group to provide opportunities for the parents of children with special needs to discuss and share experiences and feelings would be beneficial. She also believed that inviting a professional such as a social worker to the group who could help the parents fill out paperwork for requesting funds and other assistance would be beneficial because many parents of children with special needs struggle with understanding and completing formal documents properly. At the end of the interview, Amy indicated that she felt like she was contributing at least in a small way to improving the lives of parents of children with special needs by participating in the research and that the interview was helpful in reducing her stress.

Discussion

This preliminary research was conducted to gather data, collect descriptive personal information, and, from the data, suggest future practices for gaining understanding of the unique needs of parents of children with special needs. Suggested in the results of this exploratory study, is that counseling services for parents of children with special needs are both warranted and needed. The format of such services likely should be group counseling because of lower cost and potential for mutual support among group members. Such group counseling sessions should be in part psychoeducational and in part intended to foster support to meet the goals of knowledge and skill acquisition for parenting children with special needs and sharing personal experiences with others. Individual and/or family counseling might be used as a follow-up service, especially for parents or families of children with special needs who appear to need intensive care. Finally, parents of children with special needs should be able to choose how they would like to interact, such as by phone, home visit, or face-to-face because they often struggle with finding child care for when they are away from home. Having support group meetings at each other’s homes also can be an option so that parents can take turns watching children during meetings.

Limitations of this study included a small number of male participants. Whether more responses from fathers would have changed the results is only a matter of speculation. Thus, future research that includes significantly more input from fathers of children with special needs is needed. Also, to be noted is that some participants reported confusion about terms such as psychoeducation, which may have influenced their responses. Therefore, future research should identify specific services rather than the categories of services. Any online survey is limited to those who have access to the Internet and are comfortable using computers. Future studies can overcome this limitation to a great extent by incorporating multiple methods involving several types of data collection. Finally, the case interview was perhaps the most valuable part of the study in terms of revealing the reality and challenges faced by parents of children with special needs. Thus, qualitative, phenomenological research also would be beneficial, especially for understanding the unique and complex concerns of parents of children with special needs.

References

Barnett, D., Clements, M., Kaplan-Estrin, M., & Fialka, J. (2003). Building new dreams: Supporting parents’ adaptation to their child with special needs. Infants and Young Children, 16, 184–200.
Ergüner-Tekinalp, B., & Akkök, F. (2004). The effects of a coping skills training program on the coping skills, hopelessness, and stress levels of mothers of children with autism. International Journal for the Advancement of Counselling, 26, 257–269.
Goddard, J. A., Lehr, R., & Lapadat, J. C. (2000). Parents of children with disabilities: Telling a different story. Canadian Journal of Counselling, 34, 273–289.
Heiman, T. (2002). Parents of children with disabilities: Resilience, coping, and future expectations. Journal of Developmental and Physical Disabilities, 14, 159–171.
Looman, W. S., O’Conner-Von, S. K., Ferski, G. J., & Hildenbrand, D. A. (2009). Financial and employment problems in families of children with special health care needs: Implications for research and practice. Journal of Pediatric Health Care, 23, 117–125.

Chiharu Hensley, NCC, is a professional counselor in Nagasaki, Japan. The author thanks Dr. Devika Dibya Choudhuri for generously and patiently guiding me through the entire process of the current study while I was a Master’s counseling student at Eastern Michigan University, and those who willingly participated in the study. Correspondence can be addressed to Chiharu Hensley, 9-1-403 Manabino 2-chome, Nagayo-cho, Nishisonogi County, Nagasaki, Japan, 851-2130, chiharu.hensley@gmail.com.

Perceptions of Professional Counselors: Survey of College Student Views

Sep 2, 2014 | Article, Volume 1 - Issue 1

Richard A. Wantz, Michael Firmin

Numerous sources of information influence how individuals perceive professional counselors. The stressors associated with entering college, developmental differences, and factors associated with service fees may further impact how college students view mental health professionals and may ultimately influence when, for what issues, and with whom they seek support. Individual perceptions of professional counselors furthermore impress upon the overall identity of the counseling profession. Two hundred and sixty-one undergraduate students were surveyed regarding their perceptions of professional counselors’ effectiveness and sources of information from which information was learned about counselors. Overall, counselors were viewed positively on the dimensions measured. The sources that most influenced perceptions were word of mouth, common knowledge, movies, school and education, friends, books, and television.

Keywords: professional counselors, perceptions, counselor effectiveness, professional identity, undergraduates

Perception is not reality, but perception is nonetheless a very cogent relative to how humans come to understand reality. Moreover, perception tends to drive behavior and decisions made by consumers. In the present context, we are interested in how college students come to perceive human service providers across a number of variables. The constructs explored are not novel, as this genre of research has been assessed in decades past (e.g., Murray, 1962; Strong, Hendel, & Bratton, 1971; Tallent & Reiss, 1959; West & Walsh, 1975). However, we believe the topic warrants refreshed attention, particularly with the professional licensure acquired among all human service professions: psychiatrists, psychologists, counselors, marriage and family therapists, social workers, and psychiatric nurses.

The media tends to exert a cogent effect on students’ perceptions across multiple life domains, including human service professionals (Von Sydow, Weber, & Christian, 1998). Students also are affected by other information sources such as previous experiences with their high school (guidance) counselors, personal therapy, clergy, family doctors, parental influence, and input from peers (Tinsley, de St. Aubin, & Brown, 1982). Students’ perceptions of human service providers also may be affected by various campaigns, typically receiving information-influence from multiple sources that actively attempt to shape their perceptions of mental health services’ value and efficacy (Hanson, 1998).

Some human service professions have been more aggressive in how they advocate their service value to the public. Fall, Levitov, Jennings, and Eberts (2000) note that psychiatrists and psychologists generally have dwarfed counselors’ efforts at advocacy. Counselors, as a profession, have struggled significantly with their own identity (Garrett & Eriksen, 1999; Eriksen & McAulife, 1999), which likely affects this phenomenon. That is, if one’s identity is unclear to the respective professionals, then probably it will negatively affect its status among the laity (Gale & Austin, 2003). Psychology generally has lagged behind psychiatry in terms of the public’s professional perceptions (Webb & Speer, 1985), although Zytowski et al. (1988) reported that people frequently confused the terms psychiatrist and psychologist relative to function. Counseling psychologists also often seem to be confused with professional counselors in the public’s understanding (Hanna & Bemak, 1997; Lent, 1990).

Social work has existed as a vocation for over a hundred years. Kaufman & Raymond (1995) reported that the public’s awareness of the profession’s perception was somewhat negative in their survey sample. LeCroy and Stinson (2004) and Winston and Stinson (2004) likewise found individuals in their particular sample to be relatively knowledgeable regarding social workers’ responsibilities, although reported attitudes were more positive than those reported by Kaufman and Raymond. This partly may be due to the fact that respondents reported more favorable perceptions of social workers as helping those needing avocation than they did for social workers as therapists. Sharpley, Rogers, and Evans (1984) suggest that marriage and family therapy, as a profession, is relatively cryptic to the general public. That is, people generally deduce what such human service personnel do, as indicated by the title, but do not have as much first-hand knowledge or experience with such professionals as they do with counselors, social workers, psychologists, and other professionals.

Ingham (1985) notes that a helping profession’s overall image affects clinicians in that profession relative to their abilities in helping clients to utilize their services. This conclusion makes logical sense in that consumers’ confidence in the care provided is subjective and highly influenced by psychological variables, such as idiographic perceptions. Attempts at educating the public regarding an apt understanding of what a human service profession has to offer has shown various levels of effectiveness (Pistole & Roberts, 2002). Nonetheless, Pistole (2001) also notes that the general public finds the distinctions among the various human service providers to be bewildering. In short, without periodic reminders, the public’s image of various human service personnel may reconverge in a fog of misperception.

Since many individuals have never experienced the services of mental health clinicians, often their perceptions are based on reports or intuitively acquired opinions. For example, Trautt and Bloom (1982) report that fee structures affect perceptions of status and effectiveness provided by clinicians. The basic understanding, of course, is that the more expensive the treatment, the higher its perceived value and professional status. That, of course, can result in self-fulfilling prophesies—with people paying more money expecting more from therapy—and experiencing better success rates. We are unaware of any studies where clients were randomly assigned to professional therapists and (systematically) charged varying pay rates. Such a study, controlling for fee structures, might yield some valuable data to the present discussion regarding how the public perceives the value of respective human service professionals.

Beyond the public’s general perceptions on this topic, however, we are particularly focused on students’ perceptions. Hundreds of thousands of students annually utilize the services of university counseling centers, as well as private practice therapists and other human service agencies. With the added stress of academics, social pressures, being away from home for the first time, transitioning from teenage to adult responsibilities, dating, drinking alcohol, and other similar stressors, having apt utilization of psychotherapeutic services is paramount for college students. Turner and Quinn (1999) suggest that college students’ perceptions differ from the population-in-general, and research data from one group may not accurately generalize to the other.

Notwithstanding obvious developmental differences between college students and more mature adults from the general population, counseling students may not pay (directly, out of pocket) for the services available to them. Campus counseling centers, for example, typically receive funding from tuition or generic student fees, rather than students paying direct dollars for the services. Additionally, most full-time students remain on their parents’ medical insurance which also offsets financial costs involved in private practice expenses. In short, cost of services seems to be a significant variable for the general population (Farberman, 1997) that may not load with the same degree of importance vis-a-vis college students. Additionally, titles (such as “doctor”) may not have as much bearing with the general public (Myers & Sweeney, 2004) as they do with college students who routinely use such nomenclature with professors and others on a daily basis. In short, while we accommodate research findings that compare the various mental health professionals as perceived by the general public (e.g., Murstein & Fontaine, 1993), we also treat the results with some degree of prudence and believe college students represent a distinct population worthy of particular focus and exploration.

Gelso, Brooks, and Karl (1975) conducted a study that was similar in some respects to our present one. They surveyed 187 students from a large eastern university with a sample of 103 females and 84 males. Subjects were asked to rate perceived characteristics of various human service professionals, including high school counselors, college counselors, advisers, counseling psychologists, clinical psychologists, and psychiatrists. They found that overall college students did not report significant differences relative to professionals’ personal characteristics. However, they did report differences among the human service providers relative to their perceived competencies in treating various hypothetical presenting problems.

In the 30 years subsequent to this study, we are interested in how student perceptions have changed over time. Additionally, the Gelso, Brooks, and Karl (1975) study did not account for students’ perceptions of social workers, marriage and family therapists, or psychiatric nurses. Given the present milieu, we are more interested in these professionals than the categories of school counselors or advisors. Additionally, we also chose to combine the categories of counseling and clinical psychologists into the generic grouping, “psychologist.” The specific questions asked of students also differed in our present study. However, the general tenor of the two studies is similar—and we believe the updating of knowledge in this area has significant importance for those working with college students in various capacities and milieus.

Warner and Bradley (1991) also conducted a study similar to the present one. Their participants included 60 men and 60 women who were undergraduate college students enrolled in a University of Montana introductory psychology course. They assessed student perceptions of master’s-level counselors, clinical psychologists, and psychiatrists on multiple variables. Findings included students reporting their perceptions of counselors as possessing more caring-type qualities. Psychiatrists were seen as most able to address severe psychopathology and psychologists were viewed as more academics and researchers than as therapists.

Method

Participants
We surveyed 261 students from three sections of a general psychology course for this study. The course was selected, in part, because it is included in the university’s general studies core curriculum. Consequently, it represented a relatively wide range of majors from the student body and included students from freshman through senior status. The sample was taken at a selective, private, comprehensive university located in the Midwest with a study body of approximately 3,000 students. It included 167 women and 92 men with ages ranging from 17 to 55. The students were mostly Caucasian with 9% identifying themselves as ethnic minorities representing 34 states.

Procedure
The instrument was first pilot tested (Goodwin, 2005) to a group of undergraduate students at a regional state university prior to utilizing it in the present research project. Modifications were made in clarifying ambiguous terminology, instructions, and time to complete. Due to practical considerations, the instrument was designed to be completed in about one-half of a normal class period. The survey was administered during a normal class period with students having the option to participate at will without reward or penalty for doing so. Two students chose not to complete the surveys for undisclosed reasons.

The survey queried students regarding their perceptions of human service professionals (HSP), taking about 20–25 minutes to complete. Anonymity was provided to all students regarding answers to all items. Questions were asked about the overall perceived effectiveness of various HSPs, for which types of problems they might recommend various HSPs, and overall perceptions about the various HSPs. Although obviously many types of HSPs exist, this particular survey focused on psychiatrists, psychologists, professional counselors, marriage & family therapists, social workers and psychiatric nurses. In order to control for order effects as potential threats to internal validity (Sarafino, 2005), the various HSPs were presented in random order each time they appeared throughout the survey. The amount of data collected from the survey was relatively substantial. However, given the practical number of journal pages that can be reasonably devoted to presenting the information, along with our desire to comprehensively address perceptions of counselors, the present article addresses only this particular segment of the data collection.

Results

We organized the survey’s results in terms of the counseling services utilized, how effective students perceived counseling to be, for what types of problems or issues counselors are thought to be apt, how students came to view their perceptions of professional counselors, and qualities thought to characterize professional counselors. All percentages are rounded for clarity of reading and presentation, except where percentages fall below 1%.

Types of Services Utilized
At the end of the questionnaire, students were asked to confidentially self-disclose whether or not they had received services from a HSP. The question was placed at the end in order to have students already somewhat acclimated to HSPs and to have them somewhat more comfortable with the world of different types of HSPs. Of those answering the question, 28% of the participants indicated having received assistance from a HSP prior to completing the survey. The specific question asked whether or not students received prior professional assistance regarding personal, social, occupational or mental health concerns. About 3% of all the participants chose not to answer this particular question. However, of the 28% only 1% indicated that they did not know the profession of their HSP, indicating that most of the respondents who previously had utilized HSP services were aware whether the professional they saw was a counselor, psychologist, social worker, etc. Relatively few (

States possess a variety of titles by which professional counselors can or should be called (Freeman 2006). Consequently, rather than asking students simply to identify whether or not they had previously utilized the services of a “counselor,” we specified some types of counselors they may have seen. These included professional counselor, pastoral counselor, addictions or chemical dependency counselor, rehabilitation counselor, clinical mental health counselor, professional clinical counselor, and school guidance counselor.

Of the 28% of students who indicated they had previously utilized HSP services, three particular types of counselors were more prominent than the others. Namely, 16% indicated having seen a school counselor, 11% saw a professional counselor, and 9% saw a pastoral counselor. Relatively few students indicated having seen a rehabilitation counselor (0.4%), an addictions counselor (0.8%), or a mental health/clinical counselor (3%).

Perceived Overall Effectiveness
Students were asked to indicate how effective they believed professional counselors are overall. The particular question was worded as follows: In general, what is your opinion about how overall effective professional counselors would be with helping a mental health consumer? The options provided, with descriptors in parenthesis, were 1 (Positive), 2 (Neutral), 3 (Negative), and 4 (Unsure or don’t know). The intent of the question was to capture the gestalt of students’ thinking regarding professional counselors, prior to probing more deeply vis-a-vis types of counselors and for which kinds of issues they might find effective interventions.

Only 3% of the participants indicated having no opinion regarding this question. Another 3% indicated viewing professional counselors negatively. A total of 28% of the participants indicated having neutral views regarding counselors’ overall effectiveness. Sixty-six percent of the participants indicated having a positive view of professional counselors.

Types of Issues for Which Counselors Are Adept
Students were asked to identify for what types of issues they believed professional counselors would be particularly adept. They were provided with 12 different issues and asked to rate them as Yes (I would recommend a professional counselor for this situation), No (I would not recommend a professional counselor for this situation), or NS (Not sure, not familiar). Relatively few students skipped these questions or chose not to respond (range=0.8% to 3.4%). In other words, response rates were consistently high for these questions, obviously adding to the interpretation process. The same is true with students indicating that they were unsure or unfamiliar. Namely, on average 4% or so of students indicated being unsure for the situations presented (range=1.9 to 6.9). Results showed three clusters of participants’ responses.

The first cluster had four prominent responses, exhibited by 80% or more of the respondents—they involved college issues, academic problems, depression, and career counseling. A total of 91% of the participants indicated believing a professional counselor would be effective for helping college students who report homesickness, roommate problems, and falling behind with class assignments. A similar number (88%) believed that a professional counselor would be effective with a depressed individual who reports feeling sad and empty most days, finds little pleasure in daily activities, has insomnia, and is unable to concentrate. Comparable responses (83%) were seen for professional counselors addressing a young person with adequate intellectual capacity, but a pattern of academic problems (e.g., failing grades and significant underachievement). Finally, 80% of participants indicated that a professional counselor would be effective for a person reporting job dissatisfaction and uncertainty about career choices.

The next cluster of responses involved issues of family dysfunction, substance abuse, and attention-deficit hyperactivity disorder (ADHD). Seventy-six percent of participants indicated feeling that professional counselors were effective for a family unit reporting communication problems, negative interactions, criticism, and withdrawal among family members. For cases when a person self-administers and abuses drugs that results in impairment of daily academic, occupational and social functioning, 73% of the respondents in our survey believed a professional counselor would be effective. Sixty-seven percent of participants indicated that a professional counselor would be effective when a person with persistent patterns of inattention and hyperactivity-impulsivity that interferes with academic, occupational, and social function.

The final cluster of participants’ responses involved issues of personality assessment, intelligence testing, psychotic symptoms, physical disabilities, and mental health evaluations. Just over half (53%) of the participants indicated that professional counselors were apt for working with a person who needs personality assessment. Forty-four percent said that a professional counselor would be effective for a person with psychiatric symptoms who experiences delusions, hallucinations, disorganized speech, and is frequently incapable of meeting ordinary demands of life. When asked if an unemployed individual with a physical disability seeking employment would be a target source for a professional counselor, 43% answered affirmatively. Only 40% of participants indicated that a professional counselor would be effective in helping a client who needs a comprehensive mental health evaluation. Fewer (37%) indicated that intelligence testing was germane for a professional counselor.

Table 1

Sources of Perceptions about Counselors

Another line of inquiry addressed the identified sources by which students indicated they developed their perceptions about counselors. In other words, they told us about the factors that influenced them the most regarding how they came to think about professional counselors. The options from which to choose included books, common knowledge, friends or associates, HSPs, insurance company or carrier, Internet, magazines, physician or nurse, movies, newspapers, personal experience, school and education, and television. Only 2% of the participants declined to participate in this section of the survey or marked “none.”

Instructions asked students to complete this section in two steps. First, they were to indicate (by checking a corresponding box) whether or not they learned about a professional counselor from the identified source. Students were told they could select multiple sources. In the second step, they were asked to rate whether the information about the HSP was 1 (positive), 2 (neutral) or 3 (negative). Only 2% of the students marked a box described as “other,” indicating that the categories provided were relatively comprehensive. Results from this portion of the survey showed the data falling into three clusters. The two clusters representing extreme scores were of relatively equal size, while the third or middle was small (only two sources in the category).

The first cluster showed the following items as being relatively influential in how students came to understand the roles of professional counselors: common knowledge (84%), movies (63%), school and education (60%), friends (55%), books (49%) and television (44%). The middle cluster included personal experience (27%) and Internet (24%). The finding that 27% indicated personal experience to be influential is consistent with the demographic portion of the questionnaire where 28% of students said they had personal contact with a HSP prior to completing the survey. The third cluster comprised those sources that participants said were relatively non-influential in generating their perceptions of professional counselors. They included magazines (20%), physician or nurse (18%), newspaper (13%), HSPs (10%) and insurance companies (5%).

Results from the second step in the survey are more difficult to summarize. The data was more dispersed than the first step, although three clusters inductively emerged. Some items received few responses, as they were not selected very frequently in step one. The percentages listed do not add up to 100% for each item because the remaining percentage for each item is accounted by students who did not provide answers for that item. For example, if an item had 1% positive, 1% neutral, and 1% negative, then 97% of the participants simply left the question blank.

The first were items where students indicated that professional counselors were as viewed mostly positive. These included school and education (43% positive, 13% neutral and 3% negative), friends (38% positive, 10% neutral and 6% negative), books (30% positive, 17% neutral and 2% negative), personal experience (17% positive, 7% neutral and 3% negative), physicians (10% positive, 6% neutral and 2% negative), and HSPs (8% positive, 0.8% neutral and 0.8% negative).The second cluster comprised items that were rated as being mostly neutral and with relatively few positive indicators. These included: movies (14% positive, 28% neutral and 19% negative) and television (13% positive, 25% neutral and 6% negative). The third cluster showed a relative spread of responses, although there were few negatives in each category. They included: common knowledge (38% positive, 42% neutral and 3% negative), magazines (10% positive, 8% neutral 3% negative), Internet (10% positive, 12% neutral and 1% negative), newspapers (5% positive, 6% neutral and 3% negative), and insurance companies (0.8% positive, 2% neutral and 2% negative).

Perceived Counselor Qualities

The final portion of the questionnaire addressed how participants viewed various professional counselors’ characteristics. Students were asked to identify statements that they believed to be true about professional counselors, based on their overall knowledge of them. Options included competent, can be in independent private practice, diagnose and treat mental and emotional disorders, doctoral degree required to practice, intelligent/smart, overpaid, prescribe medication and trustworthy. Consistently, only 1% of the participants chose not to respond to this portion of the survey, making interpretation for this section relatively straightforward. The findings fell neatly into two categories: characteristics counselors presumably possess and those they do not.

Characteristics that students believed professional counselors possess include being competent (81%), independent private practice (81%), trustworthy, (79%), and intelligent/smart (77%). Contrariwise, participants identified the following as not characterizing professional counselors, as indicated by the relatively low percentages of marked responses: doctorate required (30%), diagnose and treat mental disorders (22%), overpaid (16%) and prescribe medications (5%).

Discussion

Given the formation and advancement of the American Mental Health Counseling Association (AMCHA), the introduction of state licensure laws that specifically use mental health counselors as formal nomenclature (Freeman, 2006), and particular certifications that have been offered in clinical mental health counseling, we were somewhat surprised that only 3% of the students who had previously used HSP services identified doing so with clinical mental health counselors. Of course, they may have been confused with names, but to the degree that accurate reporting occurred, the numbers were relatively low compared to other types of counselors.

Obviously, school counselors are very important relative to how students perceive professional counselors. They accounted for the largest portion of users (16%). First impressions are not always necessarily lasting impressions. However, they are cogent and school counselors may set the tone for how these students, for the rest of their lives, perceive others using the word “counselor” in their professional titles. This sentiment was illustrated in qualitative research findings by Wantz, Firmin, Johnson, and Firmin (2006).

Three times as many students indicated having seen a pastoral counselor than a mental health counselor (9% and 3%, respectively). Obviously, we do not know if some students actually meant that they saw an ordained clergy person for personal issues, considering this person to be a pastoral counselor, since they received counseling from him/her and the person was clergy. However, assuming accurate reporting, it suggests that graduate training programs should consider giving additional attention to this domain of counseling. Although courses in pastoral counseling sometimes are seen in religiously-oriented universities (e.g., seminaries, Catholic or Christian colleges), the apparent popularity of their use by students, suggested by the present research, provides evidence that more widespread attention to pastoral counseling is warranted.

Students’ overall perception of professional counselors as being effective is heartening. Particularly welcoming is that only 3% viewed counselors negatively. Social psychology research (Myers, 1994) has shown that a few negative, public incidences can have overshadowing effects on a group’s overall positive characteristics. Fortunately for professional counselors, whatever data might feed negative overall impressions seems to be relatively dormant for students in the present sample.

A general continuum emerged vis-a-vis students’ perceptions of what types of issues are most germane for professional counselors to address. Namely, high responses were provided for general, developmental life issues such as academic problems, depression and career counseling. Moderate responses were provided for problems where direct brain-behavior connections are involved such as ADHD or drug counseling. The lowest responses were provided for types of situations where assessment is warranted, such as personality or intellectual assessment and mental health evaluations. These findings are consistent with overall perceptions that students do not think of counselors in terms of being clinical mental health professionals, but rather as more generic, trained counselors. If the field wishes to advance itself toward the direction of diagnosis, assessment, and treating psychopathology, then data from the present survey would suggest that efforts should be redoubled.

Not all media sources appear to be equal in influencing students’ perceptions of professional counselors. For example, newspapers (13%), magazines (20%), and the Internet (24%) were relatively inconsequential when compared to movies (63%), books (49%) and television (44%). Unfortunately for professional counseling organizations, the most potentially influential sources also happen to be the most expensive ones to target. Nonetheless, if organizations such as the American Counseling Association (ACA), American Mental Health Counselors Association (AMCHA), and the National Board for Certified Counselors (NBCC) are going to impact students’ thinking, then they should target the most efficacious sources. It could be, of course, that the reason newspapers, magazines and the Internet were so relatively non-influential is that few inroads have been attempted in these domains. Advertising in university newspapers, posting and promoting user-friendly web sites, and generating informative articles in popular magazines simply may be an important need for professional counseling advocacy at this time.

In a separate study under development, using qualitative methodology, we are attempting to better flesh-out some of the details relating to these sources of impact on students’ perceptions of professional counselors, particularly the concept of “common knowledge.” Although not surveyed in this study, an influential source proved to be word-of-mouth in perception formations regarding counseling. That is, influences of school, friends, personal experience, physicians, and HSPs most likely have some type of personal connections tied to the medium. Evidently, there is some truth to the adage that word-of-mouth is the best means of advertising—assuming, of course, that the messages being relayed are positive.

In the perceived counselor qualities portion of the survey, it was somewhat disheartening that comparatively few (22%) students indicated they saw professional counselors as competent to diagnose and treat mental disorders. This finding was consistent with other data throughout the survey. Namely, students generally view counselors as professionals who address relatively normal, human development issues rather than psychopathology or more severe disorders requiring assessment, diagnosis and treatment. Again, if the counseling profession wishes to move in the latter direction, then findings from the present research suggest that there is some distance to go. Early acquired school counselor perceptions tended to initiate students’ mindsets regarding what counselors do and they seem not to have moved far from those early perceptions.

In summary, we believe that the present study is a strong first step in a line of needed research regarding just how people come to understand counselors. The findings here do not dictate any action on behalf of professional counseling organizations. However, we believe that the findings indicate in which directions the winds of student perceptions are blowing—and that is data which should be considered when making policy decisions. If counselors are going to move to new, future levels of excellence in terms of public perception, then paying attention to this type of data and giving it due consideration is an important initial component.

Limitations and Future Research

All good research studies report limitations (Murnan & Price, 2004) and we indicate four of them here. First, while our sample had several strengths, including adequate size (Patten, 1998), high response rate (Stoop, 2004), and lack of incentives/bribes for participation (Storms & Loosveldt, 2004), it was taken from a single locale. Some compensation exists, such as students coming from 34 states and the relatively broad cross-section of college majors represented. However, future research in this domain should assess students from a wider variety of institutions such as research universities, state universities, and liberal arts colleges—as well as from diverse locales in the country in order to enhance the study’s external validity (Cohen & Wenner, 2006).

Second, our study had relatively low representation from minority students. This simply was an artifact of the university where the data was collected. Specifically, minorities comprised only 6% of the student body population. Further research should contain samples with larger representations of minority individuals. Additionally, replicating this present study with all minority students would provide an interesting comparison among many points of investigation.

Third, some of the items queried were selected a priori. While we believe them to be of interest and germane to our purposes, future research should broaden questionnaires to include questions that are derived empirically from the research literature. Also, organizations such as the Council for Accreditation of Counseling and Related Educational Programs should provide input vis-a-vis questions that directly would enhance their efforts in counselor education preparation. The same is true with potential input from NBCC and ACA as they market professional counselors to the general population as well as college students.

Fourth, in retrospect there are two particular changes we would have made to the survey instrument. One is that we would have added a Likert-scale to the first question, querying the perceived overall effectiveness of counselors. While we believe that rating professional counselors with three choices was useful—and we would keep the question—we also would recommend future researchers add a Likert-scale question that is anchored with descriptions, but to which numeric interval-scale values could be assessed. Second, looking back on our questionnaire, we would have asked how many students saw more than one HSP. That is, did they use more than one type of human service professional’s services (e.g., they saw both a rehabilitation counselor and a school counselor). Accounting for multiple uses within the same clientele could provide potentially useful data.

Future research should take the present study and apply it to the population in general. That is, we produced what we believe to be fairly apt representations of perceptions among students—but they do not represent the population at large. Obviously, college students have unique features of adult development that are not necessarily shared by older adults (Foos & Clark, 2003). The very low reported influence that health insurance companies have on college students’ perceptions is one of many examples of where student ideations and those of more middle-aged adults might differ.

And finally, qualitative research is needed in this area. A prime value of questionnaires, such as the present one, is that more voluminous amounts of data can be collected—providing breadth of understanding (Gall & Borg, 2003). Such research also tends to answer “how many” or “what” types of questions (Hittleman & Simon, 2003). Thicker descriptions are needed to help flesh-out some of the details on which survey research was only able to skim. Answers to some of the “why” and “how” questions that the present findings raise can best be answered with follow-up qualitative research methodology (Flick, 2002).

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Richard A. Wantz, NCC, is a Professor at Wright State University, and Michael Firmin, NCC, teaches at Cedarville University, both in Ohio. Correspondence can be addressed to Richard A. Wantz, Wright State University, Department of Human Services, 3640 Colonel Glenn Highway, Dayton, OH, 45435, richard.wantz@wright.edu.

The Symbiotic Relationships of the Counseling Profession’s Accrediting Body, American Counseling Association, Flagship Journal and National Certification Agency

Sep 1, 2014 | Article, Volume 1 - Issue 1

Joel F. Diambra, Melinda M. Gibbons, Jeff L. Cochran, Shawn Spurgeon, Whitney L. Jarnagin, Porche’ Wynn

To inform and guide their practices, counselor educators would benefit from having a clearer picture of how the research literature and professional standards of the field correspond and contrast. To elucidate this relationship, researchers analyzed 538 Journal of Counseling and Development articles published from 1997–2006 for fit with the 2001 and 2009 eight core areas of Council for Accreditation of Counseling and Related Educational Programs (CACREP). The articles fell into three tiers delineated by year and based on the number of articles assigned to each core area. Human Growth and Development and Helping Relationships are the two core areas most frequently represented across the 10 year time span examined.

Keywords: professional standards, research literature, CACREP, NBCC, ACA, Human growth and development, helping relationships

There is an inherent symbiotic relationship that exists among related professional organizations. Within the counseling profession, there are a number of organizations or entities that coexist, support one another, encourage and challenge one another, disseminate information, and act as gatekeepers. These major counseling entities include the American Counseling Association (ACA), the National Board of Certified Counselors (NBCC), the Council for Accreditation of Counseling and Related Educational Programs (CACREP) and the Journal of Counseling and Development (JCD). These entities mutually influence each other by acting and reacting to needs, changes and research findings within the counseling profession.

Given the new CACREP 2009 standards, it is now time for counselor educators to review and possibly revamp their training programs to better reflect the current issues faced by those in the counseling field. Counselor educators will benefit from having a clearer picture of how our research literature and professional standards correspond and contrast to inform and guide our practices.

As the respective flagship journal and primary accrediting standards of the counseling field, the JCD and the CACREP standards are predominant guiding resources that reflect, communicate, and shape the values, interests, and work of counselor educators. As JCD is the journal for ACA, and as the National Counselor Examination is based on CACREP requirements, an obvious extension to include these entities occurs as well. These entities also influence each other. JCD and CACREP can be seen as leaders of an input loop in the counseling profession. JCD, as the flagship journal for the American Counseling Association (ACA), shapes counselors’, stakeholders’ and counselor educators’ views of the counseling field. Continuing the loop, every seven years CACREP engages in a review of its standards for counseling programs. This review includes invitations for input from all counselors and stakeholders (Bobby & Kandor, 1995). As the revised standards are enacted in CACREP and CACREP-modeled programs, the standards influence the education and licensing of counselors, which then influences the work, research, writing, and submissions to JCD from the counseling field over time; JCD article topics, content, and methodology loop again to inform counseling practitioners, students, and educators.

While the 2009 CACREP standards revisions are implemented into counseling programs, it seems an important time for counselor educators to reflect on and explore the profession’s flagship journal articles in relation to future CACREP standards and to discuss future counseling literature that will shape and inform directions for counselor educators and the counseling field. Calls for a strong professional counselor identity (CACREP, 2009; Gale & Austin, 2003; Goodyear, 1984; Hansen, 2003) and professional unity from a recent ACA President (Canfield, 2007) would also seem to indicate the need to reflect on and gain perspective from the trends and foci of our professional literature. The current study provides an analysis and discussion of the fit of JCD articles from 1997–2006 with the eight core areas in both the 2001 and adopted 2009 CACREP standards. We selected this 10-year span because the research project began in late 2007 and 2006 represented the last complete year of JCD articles at that time. We hope such an analysis will help illuminate areas for potential change in counselor education programs.

Professional Organizations and Publications in Counseling

American Counseling Association
With its roots as far back as 1952, ACA is the world’s largest association focused exclusively on representing professional counselors. As reflected on their website, “The ACA is dedicated to the growth and development of the counseling profession and those who are served” (ACA, 2010). Its mission is to enhance the quality of life in society and promote the development of professional counselors, advance the counseling profession, and use the profession and practice of counseling to promote respect for human dignity and diversity (ACA). ACA has 56 chartered branches in the U.S., Latin America and Europe and currently boasts 42,594 members. To communicate to its membership and inform the profession of contemporary issues and treatment modalities, ACA publishes an online website, numerous textbooks, Counseling Today (its monthly magazine) and JCD (its official journal).

Journal of Counseling and Development
In addition to being ACA’s primary journal, JCD appears to have grown to a significant readership, and this is particularly interesting considering that at least two-thirds of ACA members receive JCD as their only ACA journal. According to ACA (personal communication, Rae Ann Sites, December 20, 2007), the JCD Winter 2008 issue had a total print run circulation of 43,500 journals. Approximately 1,000 of these subscribers are institutional subscribers (i.e., college/university libraries). Therefore, it seems logical to assume the majority of subscribers are individual ACA members.

Members also have the option to join one or more of 17 divisions within ACA and many of these divisions publish their own journals. As of December 20, 2007, the cumulative membership in these 17 divisions was 16,279. At most, division membership could represent 37% of ACA members, but it is important to note that some ACA members join multiple divisions, thus exaggerating the 37% figure. Following ACA’s 1997 decision to allow ACA membership exclusive of a division membership and the 2004 decision to permit division separation from ACA, the American Mental Health Counseling Association (AMHCA) and American School Counseling Association (ASCA) announced independence from ACA and are no longer included in these 17 divisions. ACA data available from June 30, 2007, indicate 2,182 (approximately 5%) of ACA members who also were AMHCA members and 2,648 (approximately 6%) who also were ASCA members (personal communication, Jennifer Bauk, December 3, 2007). When compared to the total membership figures of these two professional counseling organizations (AMHCA, 5,860 [personal communication, Mark Hamilton, November 27, 2007]; ASCA, 23,021 [personal communication, Jennifer Bauk, December 3, 2007]), the percentage of AMHCA members who joined ACA was 37% and ASCA members 16%. From these data, it is apparent that JCD is circulated to a wide and diverse counselor audience. Therefore, we can assume that many graduates of our training programs will read only JCD as their professional journal to inform them of current issues and important research.

Council for Accreditation of Counseling and Related Educational Programs
CACREP has evolved to be a significant influence on the counseling field. A brief recap highlights CACREP’s growing influence. Bobby and Kandor (1992) reported that 44 programs housed within 16 institutions were granted approval by CACREP’s Board of Directors at the Council’s first meeting in 1981. In 1992, 195 programs had gained accreditation (Bobby & Kandor); and in 2004, that number had risen to 434 (McGlothlin & Davis, 2004). Currently, CACREP has accredited 505 programs housed within 210 institutions across 48 states, the District of Columbia, and Canada. In addition, 117 programs are currently being considered for CACREP accreditation. This is evidence of CACREP becoming more wide spread and ingrained within the counseling profession (CACREP, 2007).

National Board for Certified Counselors
Developed in 1982, NBCC conducts a national certification program for professional counselors; it is one of two leading certification organizations for the counseling profession, the other being the Commission on Rehabilitation Counselor Certification (CRCC). Although initially created by ACA, NBCC operates as an independent body without direct connection to ACA. Currently, over 46,000 counselors hold the National Certified Counselor (NCC) credential (NBCC, n. d.). In 41 states (82%), NBCC’s National Counselor Examination (NCE) is used as part of the licensure process.

The NCE contains eight content and five work behavior areas. The eight content areas mirror those in CACREP’s core curriculum and include human growth and development, social and cultural foundations, helping relationships, group work, career and lifestyle development, appraisal, research and program evaluation, and professional orientation and ethics. The five work behavior areas include fundamentals of counseling, assessment and career, group, programmatic and clinical intervention, and professional practice (NBCC, n. d.). Given this consistent overlap in core components and the growing use of the NCE for state licensure requirements, it is apparent that NBCC, ACA, JCD, and CACREP are linked in their view of what effective counselors need to know.

Support for Professional Organizations in Counseling
CACREP, JCD and NBCC have been the focus of several empirical studies. Over the past 10 years, researchers have examined issues pertaining to CACREP standards including supervision (LaFountain & Baer, 1999), spirituality and religion (Burke, Hackney, Hudson, Maranti, Watts, & Epp, 1999), community counseling (Hershenson & Berger, 1999), and school counseling (Holcomb-McCoy, Bryan, & Rahill, 2002). Haight (1992) investigated the CACREP standards, focusing on the quality of the standards. In addition, researchers have explored CACREP standards’ relevance to counselor preparation (Vacc, 1992) and their perceived benefit for practitioners (McGlothlin & Davis, 2004). Although some researchers have challenged the standards, most reviews and discussions related to CACREP have been favorable (Schmidt, 1999).

Vacc (1992) investigated counselor educator perceptions of the 1988 standards relevance to the preparation of counselors. He found that respondents judged each of the eight CACREP core areas as crucial or important to counselor preparation. Percentages of perceived importance ranged from 91% to 100%, with Social and Cultural Competence perceived as least relevant and Group Development, Dynamics, and Counseling Theories perceived as most relevant. Based on these findings, Vacc concluded that the data provided evidence to support the validity of the standards.

McGlothlin and Davis (2004) investigated perceived benefits of the CACREP standards. They surveyed counselors to determine perceptions of the benefits of the 2001 core curriculum standards. The core curriculum standards were perceived as being beneficial overall. Ranked in order of perceived benefit (highest to lowest) were: Helping Relationships, Human Growth and Development, Social and Cultural Diversity, Group Work, Professional Identity, Assessment, Career Development, and Research and Program Evaluation. Both studies established credibility for CACREP’s eight core standards.

As noted earlier, NBCC provides the examination used for professional licensure in the U.S. (NBCC, n. d.). Support exists for NBCC due to its oversight of the NCE. Adams (2006) compared NBCC National Counselor Exam scores across CACREP and non-accredited programs. She found that graduates of CACREP-accredited programs scored significantly higher than those from non-accredited programs. Pistole and Roberts (2002) encourage licensure as a primary way to secure professional identity. Similarly, Calley and Hawley (2008) identified professional certification and licensure, along with membership in professional organizations such as ACA, as ways counselor educators help promote a professional counseling identity. Support for both NBCC and the NCE is evident and furthers counselor professional identity.

JCD publications can be seen as shaped by a number of forces and as evolving over time. For example, Weinrach (1987) argued that JCD had been fashioned by contributors’ articles and editors’ aims. Twelve years later Williams and Buboltz (1999) asserted that JCD publications were influenced by changes within society, evolving counselor and student needs, the teaching aims of professors, and most importantly by the research and practical topics that are popular during a historical period.

The content analysis by Williams and Buboltz (1999) of volumes 67–74 most closely resembles the aims of the current study. Their article analysis covered a nine-year span and cross-classified articles into 11 categories (e.g., Counselor Selection, Training and Evaluation, Personal Development and Adjustment, Technology and Media, and Special Groups) and sub-grouped articles by editorship. The purpose of their study was to identify possible topic changes and trends over time and JCD editors. Overall ranking of topics pertinent to the 8 core areas identified by CACREP included Individual, Group Counseling, and Consultation ranked first, Special Groups third, Vocational Development and Adjustment/ Career Counseling seventh, and Technology and Media tenth.

In this study, ACA is assumed to be represented by its flagship journal, JCD, while NBCC is represented by CACREP, as the NCE is based on CACREP accreditation standards. To date, no study has analyzed JCD article content by CACREP core areas. In addition, no study could be found that focused on the similarities and differences between what is required for appropriate training and licensure of counselors and what is represented in the flagship journal of the counseling profession. Therefore, the purpose of the current study is to provide that analysis and discussion for the consideration of counselor educators and the counseling field.

Method

Procedure

Using first the 2001 standards and later the 2009 revisions, two researchers used a qualitative content analysis method to sort articles into the eight CACREP core areas. The eight CACREP core areas included Professional Orientation and Ethical Practice; Social and Cultural Diversity; Human Growth and Development; Career Development; Helping Relationships; Group Work; Assessment; and Research and Program Evaluation. Researchers independently analyzed content by sorting articles by CACREP core area. As per classic content analysis procedures described by Ryan and Bernard (2000), researchers assumed that the eight 2001 CACREP core curricular experience areas were the pre-defined codes of interest. Because of the time span from which articles were analyzed (i.e., 1997–2006), the researchers determined that both an analysis of the 2001 and 2009 standards was appropriate given that the 2001 standards were adopted during this time period and analysis of the 2009 standards would provide insight as to how previous articles would fit into the future standards.

First, researchers independently analyzed the JCD articles using the 2001 standards. After independent analysis, the two researchers compared findings, identified matching results and noted findings on which they differed. A list was established identifying the articles on which the two researchers disagreed. The same two researchers independently reanalyzed these articles and then met to compare findings again. No comparisons were made between the first and second attempts in order to maintain the independence of the second analysis. After this second attempt, the researchers obtained a cross-rater reliability of .93 for the 2001 data. Of the remaining articles for which coding differed, 20 differed in coding for CACREP core area. These articles were equally distributed throughout the 10 years of JCD being analyzed and were not representative of a single time period or editor. These remaining articles were coded by a third researcher, once again independent of the first two analyses. The three coders then reviewed each article together and, through consensus, determined the best placement for each.

After completing analysis using the 2001 CACREP standards, the two researchers addressed the data using the 2009 CACREP standards. The researchers noted that the eight core CACREP area titles remained constant between 2001 and 2009. However, differences between the 2001 and 2009 standards included changes within the eight core areas. Changes typically included additions of specific counseling related practices into core areas. Within the Professional Orientation and Ethical Practice core, additions were made related to crisis management and counselor self-care. Under Social Cultural Diversity, counselor self-awareness, social justice, and cultural skill development were added. In the Human Growth and Development core, additions included the effects of crises on individuals and theories of resiliency. The Career Development core remained relatively unchanged. Helping Relationships added crisis response and wellness orientation. Group Work and Assessment core areas remained substantively unchanged while Research and Program Evaluation incorporated evaluative measures and ethics related to research (CACREP, 2009). One overall change appeared to be that culturally inclusive language was more represented across most of the core areas. With these changes in mind, the two researchers independently re-reviewed titles and abstracts of all articles for 2009 CACREP core area best fit.

Analysis

The total number of articles in the JCD 1997–2006 issues was 538, excluding minutes from ethics committees and calls for editorial board members. Researchers examined 479 out of the 538 possible articles. Fifty-nine articles (11%) were eliminated from coding including interviews of well-known counselors and reviews of other articles (typically found in the Trends section). These articles did not fit into the predetermined coding categories. In all cases, an attempt was made to select only one option per area. Coding was based on the core area which was most representative of describing the article. For the 2001 Standards, approximately 7% of the cases (35 of 479 articles), were impossible to fit into only one area, so two areas were selected for coding. Three additional articles needed two areas after being reanalyzed with the 2009 Standards. For example, some articles were equally about a client issue and how counselors could effectively address the issue. These articles were coded as representative of both the Human Growth and Development and Helping Relationships core areas. In the two cases that no CACREP core area was found to match the article, an ‘Other’ category was selected. This category was used only when both researchers found it impossible to connect the article to a CACREP area.

When analyzing JCD articles using the 2009 CACREP core areas, researchers identified 97 articles that required reanalysis. These 97 articles were fully analyzed again. Fifty-nine of the 97 articles remained unchanged from the original assigned coding. Three articles were changed from representing two core areas to just one core area. Six articles were changed from representing one core area to two core areas (included originally coded CACREP core area plus one additional CACREP core area). Twenty-nine articles were recoded to a new core area.

Results

Due to the fact that only 29 (6%) of the 479 articles differed across core areas coding from the 2001 to 2009 CACREP standards, and because the proportional ranks remain the same, researchers are providing the 2009 CACREP Standards results, as 2009 is the current standard. CACREP core area results are presented in Table 1. The core area with the most articles was Human Growth and Development, followed by Helping Relationships and Social and Cultural Diversity. Group Work, Research and Program Evaluation, and Career Development were the least represented core areas. Thirty-eight of the articles were coded in two core areas, and all of the core areas were represented at least twice in a two-coded article. Seventeen of the two-coded articles involved Social and Cultural Diversity, 15 involved Helping Relationships, and 14 involved Human Growth and Development.

Table 1

Rankings of core areas by percentage of articles tended to be stable throughout the 10-year focus period of this study. Human Growth and Development and Helping Relationships had the top two highest percentages of articles in the 10-year average and maintained consistently high percentages across the years, having been the first or second largest article category each year, except one. Within our analysis, these core areas formed the highest tier. Social and Cultural Diversity and Professional Orientation had the third and fourth highest percentages of articles and were ranked third or fourth each year (except one year for Professional Orientation and two years for Social and Cultural Diversity, affected by a special issue focused on that topic in 1999). Within our analysis, these core areas formed the middle tier. Assessment, Career Development, Research and Program Evaluation, and Group Work consistently varied from fourth to eighth in article percentages and formed the lowest tier of the rankings. These core areas not only occupied the lowest tier, but the percentages of articles representing them were noticeably lower than those representing the four leading core areas.

Table 2

Results by CACREP Core Areas across the ten year span are presented in Table 2. Over the 10-year period, most CACREP core areas are equivalently represented with minor fluctuations between years. Human Growth and Development and Helping Relationships are the two core areas most frequently represented and are reasonably consistent in percentage of articles representation from year to year across the 10 years. Human Growth and Development core area articles ranged in frequency from 8 to 19 across the years with a mean of 13.6 articles per year. Helping Relationships articles ranged from 6 to 16 with a mean of 12.1 articles published per year. Professional Orientation is the most consistent core area from year to year (range of 4 to 9 articles) with a moderate number (mean = 6.7) of articles published per year. Social and Cultural Diversity fluctuates substantially from year to year with a low of 2 articles published in 1997, a high of 30 articles in 1999 and a mean of 10.2 for all ten years. Assessment articles are relatively steady from year to year, yet low in number with a range from 0 to 7 articles each year and a mean of 2.9 articles per year. Research and Program Evaluation is similar to Assessment in low but steady frequency across the years with a range from 0 to 5 articles and a mean of 2.1 per year. Notably, Research and Program Evaluation articles increased slightly in the latter five years. Career Development is low in frequency, but less steady across the years with a range from 0 to 6 and mean of 2.8 articles per year. Notably, only 3 articles were published in this core area in the last three years of this study (i.e., 2004–2006), one article each year. Lastly, Group Work article frequency ranged from 0 to 3 and the lowest average frequency at .9 per year. In the last three years no articles were published in the Group Work core area.

Discussion

Having established the symbiotic relationship between four central counselor entities (i.e., CACREP, ACA, NBCC and JCD), the researchers focused their review on the overlap between the required CACREP training core and the topics represented in the counseling profession’s flagship journal, JCD. We were primarily interested in relating the content of articles from 1997–2006 to the eight CACREP core areas. When we began our study, we made the assumption that JCD and CACREP served as informative tools for its members and that CACREP standards were an appropriate measure of adequate counselor training. JCD purports “to publish articles that inform practicing professional counselors with diverse populations in a variety of settings and that address issues related to counselor education and supervision, as represented by the membership of the American Counseling Association” (JCD, n.d.). Whereas many specialty journals highlight one specific aspect or one core area, JCD attempts to provide relevant information that cuts across all CACREP core areas. Additionally, CACREP reports being “dedicated to (1) encouraging and promoting the continuing development and improvement of preparation programs, and (2) preparing counseling and related professionals to provide service consistent with the ideal of optimal human development” (CACREP, n.d.). In the counseling flagship journal and accrediting body, a goal exists to prepare, train, and provide counselors with information necessary to good clinical practice. As stated earlier, JCD is the journal representing ACA, and NBCC bases the NCE on current CACREP standards.

The results highlight an overlap between the missions and goals of JCD and CACREP with a weighted emphasis in key CACREP core areas. Results in Table 1 indicate that almost 70% of the articles published during this time period fall under three CACREP areas: Human Growth and Development, Helping Relationships, and Social and Cultural Diversity. It seems sensible and fitting to us that JCD articles would emphasize these areas. Remley and Herlihy (2007) stated that one of the essential beliefs in the counseling profession is that problems individuals face in life are developmental in nature. JCD’s emphasis on Human Growth and Development aligns with CACREP’s view that counseling helps clients work toward optimal human development. Additionally, the focus on Helping Relationships in JCD seems appropriate given the preponderance of research and literature across time that support relationship variables as most important in predicting outcome in counseling (e.g., Bergin & Lambert, 1978; Cochran & Cochran, 2006, Krumboltz, Becker-Haver, & Burnett, 1979; Lambert & Okiishi; 1997; Lubersky et al.,1986; Norcross, 2002; & Wampold, 2001). Finally, the 2009 CACREP standards support both a broad definition of Social and Cultural Diversity as a core area and the more specific recommendation of incorporating this concept into every course. This change relates to the current belief that cultural issues are not separate from other aspects of counseling, but rather integrated into all counseling activities.

Results indicated subtle yet notable shifts in the literature focus from those in previous research studies. For example, when Vacc (1992) investigated counselor educator perceptions of the CACREP standards relevance to the preparation of counselors, he found Social and Cultural Competence perceived as least relevant while results of the current study indicate Social and Cultural Diversity as in the middle tier of topic occurrence in JCD from 1996–2007. This seems to reflect the increased emphasis given to Social and Cultural Diversity within the counseling field in the last 20 years. Additionally, Vacc found Group Development and Dynamics was perceived as one of the core areas considered most relevant by counselor educators. The current study indicates that JCD articles focused on Group Work ranked in the lowest tier of frequency of occurrence. This could indicate a shift in importance over time or incongruence between counselor educator perceived importance and the number of JCD articles published in core areas. Finally, whereas group counseling and vocational development were covered extensively in JCD in the mid-1980s and early 1990s (William & Buboltz, 1999), our findings demonstrated considerably less focus on these areas over the last 10 years. Clearly, some important shifts in the literature have occurred over the past 25 years.

We find it important to also note the match between the ranked frequencies of JCD articles within the CACREP core areas and the results of McGlothlin and Davis’ (2004) study of the core areas perceived benefits. McGlothlin and Davis’ survey results ranked counselors’ perceptions of the importance of the core areas in nearly the exact rank of article frequency in JCD by core area. This suggests an overall match between publication patterns of JCD and the valuing of CACREP core areas among counselors.

Implications for Counselor Educators and Practitioners

It is clear that the articles published in JCD follow many of the trends suggested by CACREP as training requirements for counselors. If, however, as the earlier statistics suggest, JCD is the only professional journal received by the majority of ACA members, it is important for practitioners to recognize that they may not regularly be receiving as much ongoing information in these core areas compared to others, especially if they are only receiving JCD. Career development is viewed as a central factor in the lives of most people (Betz & Corning, 1993). For counselors working with children and adolescents, career development is influenced by a multitude of factors, including perceived barriers and supports (Kenny, Blustein, Chaves, Grossman, & Gallagher, 2003), family background (Eccles, Vida, & Barber, 2004), and self-efficacy beliefs (Pinquart, Juang, & Silbereisan, 2003). In adults, career-related concerns are linked with traumatic experiences (Strauser, Lustig, Cogdal, & Uruk, 2006), relationship problems (Risch, Riley, & Lawler, 2003), and overall stress (Pinquart et al.). Clearly, most counselors will encounter a need to discuss career-related issues with their clients, yet findings suggest that counselors may not receive a robust and ongoing supply of contemporary theoretical or research-based treatment approaches on this topic in JCD.

In addition, many counselors have the opportunity to facilitate groups as a part of their work. Vacc’s (1992) finding that counselor educators perceived Group Development and Dynamics as one of the most relevant core areas to the preparation of counselors and McGlothlin and Davis’ (2004) finding that Group Work ranked fourth in perceived benefit of the CACREP standards suggests that Group Work may be of importance to current working counselors, even though it is not well represented in JCD. Continuing education through professional journals can be a way to keep counselors-in-training, practicing counselors, supervisors and counselor educators abreast of new research and ideas regarding career and groups. Counselor educators, as well as clinical supervisors and counseling practitioners, would benefit by realizing that supplemental journals are needed to ensure adequate information on group dynamics is reaching their students and supervisee’s or informing their counseling practice.

Research and Program Evaluation and Assessment also received less representation in JCD. Counselors-in-training often struggle with these subjects or report disliking the bland content of these courses (Stockton & Toth, 1997). In fact, Bauman (2004) surveyed school counselors and found only 49% agreed or strongly agreed that they felt prepared to critique research, and only 43% agreed or strongly agreed that they had the skills needed to complete a research project on their own. Currently, a call in the profession exists promoting practitioners to conduct research in the field (Kaffenberger, 2009; Niles, 2003; Whiston, 1996), but with these feelings about research and assessment, it is unlikely that many will do so. Practitioners need to look beyond JCD for professional development on becoming competent and self-assured researchers. Knowing that a single journal is not the best option for gaining research self-efficacy might push practitioners to seek help elsewhere, rather than simply continuing on without furthering their knowledge.

Counselor educators and students can benefit in general from the findings of this study. For example, when conducting literature reviews or submitting research manuscripts for review, results provide guidance as to which counseling-related topics are more frequently or less frequently addressed in JCD. Results help to inform counselor educators when to best use and recommend JCD as an initial resource or different journal when they or their students are investigating specific topics within CACREP core areas. Additionally, one could argue that results suggest a reason to join multiple professional counseling organizations such as ASCA or AMHCA, or join the smaller sub-interest groups (e.g., National Career Development Association and Association of Specialists in Group Work) when first joining ACA or renewing their ACA membership. Overall, having more information available on major sources of training and continuing education can only assist practitioners and educators in their roles.

Implications for Future Research

Although this study provides an analysis of JCD articles over a 10-year period, with CACREP guidelines, additional research in this area is needed. Several ideas for future research foci are provided as preliminary courses of action. Researchers could help to identify students’, counselor educators’ and working counselors’ perceptions as to the importance of some of the lesser represented areas, such as Career and Group. Additionally, perceptions from these same constituents on how JCD, ACA, NBCC, and/or CACREP shape their views of the counseling field seems to be worthy of investigation. More research focused on specific CACREP areas and articles from other journals (e.g., the types of articles that represent each CACREP area and the impact on continuing education and training of future counselors) would further illuminate the relationship between the accrediting body and the counseling journals in general. Regardless of the exact focus of future research, it is clear that there is a link between the counseling accrediting body and the flagship journal. Further research is needed into how JCD and other counseling journals, along with CACREP and NBCC, may have or will influence each other over time.

Conclusion

It is our hope that the findings of the present study will be included in the perpetual input loop linking ACA, NBCC, JCD, CACREP and the counseling profession. With CACREP’s 2009 accreditation standards being implemented, we believe now is a good time for the counseling profession to re-examine the roles of the major counseling entities’ relationships to each other. Continuing this discussion, especially focusing on CACREP and ACA, may help strengthen the unity of our profession and further cement our identity as professional counselors.

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Joel F. Diambra, NCC, Melinda M. Gibbons, NCC, Jeff L. Cochran, NCC, and Shawn Spurgeon, ACS, teach Counselor Education at the University of Tennessee at Knoxville. Whitney L. Jarnagin, NCC, teaches at Walters State Community College. Porche’ Wynn is a counselor education doctoral candidate at the University of Tennessee. Correspondence can be addressed to Joel F. Diambra, University of Tennessee at Knoxville, 449 Claxton Complex, 1122 Volunteer Blvd. Knoxville, TN, 37996-3452, jdiambra@utk.edu.