“Take Your Kung-Flu Back to Wuhan”: Counseling Asians, Asian Americans, and Pacific Islanders With Race-Based Trauma Related to COVID-19

Stacey Diane Arañez Litam

Following the outbreak of COVID-19, reports of discrimination and violence against Asians and Asian Americans and Pacific Islanders (AAPIs) have increased substantially. The present article offers a timely conceptualization of how public and societal fears related to COVID-19 may contribute to unique mental health disparities and the presence of race-based trauma among AAPIs residing in the United States. The relationships between media, increasing rates of xenophobia and sinophobia, and racial discrimination are provided. Next, the deleterious effects of race-based discrimination on the emotional and physical well-being of people of color and Indigenous groups (POCI) and AAPIs are described. Finally, the article identifies the clinical implications of counseling AAPI clients, encourages a decolonization of current trauma-focused interventions, and presents specific strategies to heal race-based trauma in AAPI client populations.

Keywords: race-based trauma, discrimination, microinterventions, xenophobia, sinophobia

The outbreak of novel coronavirus (COVID-19) has led to unparalleled events across the United States and worldwide. Hospitals, nursing homes, and medical settings were quickly overwhelmed, and the vulnerability of these systems became apparent. A lack of federal consistency and political infrastructure resulted in differences across levels, quality, and types of state support. On January 31, 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern. This sentiment was echoed by U.S. President Donald Trump on March 13, 2020, who warranted the pandemic an emergency for all states, tribes, territories, and the District of Columbia (Federal Emergency Management Agency [FEMA], 2020). A “shelter-in-place” order was instituted for many states and people were encouraged to stay home to prevent the spread of COVID-19. Indeed, the presence of COVID-19 has led to unprecedented times. However, the sociopolitical disparities illuminated by COVID-19 are not solely limited to institutional and political problems.

Asian Americans and Pacific Islanders (AAPIs) represent the fastest growing ethnic or racial group in the United States. In 2015, approximately 20.9 million people identified as AAPIs (Lopez et al., 2017). As a group, AAPIs encompass 40 distinct subgroups, each of which demonstrates heterogeneity across language, educational background, religion, immigration/migration history, beliefs about mental health, and attitudes toward help-seeking behaviors. For the purpose of this article, AAPIs are people who have origins rooted in East, South, and Southeast Asian countries. The present article offers a timely conceptualization of how public and societal fears related to COVID-19 may contribute to unique mental health disparities and race-based trauma in AAPIs residing in the United States. The relationships between media, increasing rates of xenophobia and sinophobia, and racial discrimination are provided. Next, the deleterious effects of race-based discrimination on the emotional and physical well-being of people of color and Indigenous groups (POCI) and AAPIs are described. Finally, the article identifies the clinical implications for counseling AAPI clients, encourages a decolonization of current trauma-focused interventions, and presents specific strategies to heal race-based trauma in AAPI client populations.

Xenophobia and Sinophobia in Media
The emergence of new infectious diseases historically has led to discrimination against groups of people of non-European descent (White, 2020). Indeed, the history of international infectious disease has predominantly been framed from a distinctly European perspective, which has focused on how disease negatively impacted post-colonial sites and affected trade (White, 2020). Experiences of fear and anxiety related to infectious disease often occur when people become threatened by an illness perceived as originating from outside one’s community (Taylor, 2019). Thus, the resurgence of attitudes characterized by xenophobia, or a fear of foreigners (Sundstrom & Kim, 2014), and sinophobia, which can be understood as the “intersection of fear and hatred of China” (Billé, 2015, p. 10), perpetuates a legacy of discrimination against non-White groups because of fear of illness. AAPIs have experienced a long tradition of blame and discrimination in the United States. Scapegoating AAPIs in light of COVID-19 echoes the racist “Yellow Peril” stereotype, which vilified Asian groups as a threat to job and economic security in Western nations (Kawai, 2005). The Chinese Exclusion Act of 1882, which effectively banned the immigration of Chinese persons to the United States for 10 years, further evidences historical anti-Chinese sentiments and an extensive history of discrimination against AAPIs in America (Lee, 2002).

The problematic, biased, and misleading media coverage of COVID-19 has led to increased rates of racial discrimination and sinophobic attitudes toward Chinese nationals and people of Asian origin (Wen et al., 2020). Health-related fears and phobia have been linked to misinformation fueled by sensationalist headlines (Taylor & Asmundson, 2004). Media, especially social media and the internet, are indispensable resources for information, communication, and entertainment. Following the outbreak of COVID-19, reports of discrimination and violence against Asian Americans have increased substantially across the United States (Congressional Asian American Pacific American Caucus [CAPAC], 2020).

COVID-19–related fears have resulted in the persecution of AAPIs through violent attacks (CAPAC, 2020), discrimination against their businesses, and sinophobic portrayals in media and from elected leaders (National Association for the Advancement of Colored People [NAACP], 2020). The dissemination of racially targeted content in media includes hate speech toward Chinese people, harassment, discriminatory stereotypes, and conspiracy theories (CAPAC, 2020; Schild et al., 2020; United Nations Human Rights, Office of the High Commissioner, 2020). A data analysis of two popular web platforms found a significant rise in racial slurs, invoking earlier attitudes of sinophobic propaganda. To better understand the emergence of sinophobic attitudes within online communities, Schild and colleagues (2020) collected and analyzed 222,212,841 tweets and 16,808,191 posts from Twitter and 4chan imageboards, respectively, from November 1, 2019, to March 22, 2020. The results revealed a significant increase in the presence of racial slurs that targeted Asians and Asian Americans, including “Kung-Flu,” “Ching Chong,” and “asshoe,” a term used to denigrate the accent of Chinese people speaking English (Schild et al., 2020). “Chink” was the most popular sinophobic slur and increased substantially after Donald Trump referred to COVID-19 as “the Chinese virus” (Schild et al., 2020).

Marginalized Groups Uniquely Affected
Social inequities and policies related to COVID-19 may disproportionately affect people of color and other marginalized groups, including individuals who are homeless, people with non-dominant racial and ethnic identities, undocumented individuals, people in lower socioeconomic groups, and individuals with limited access to health care. Individuals who lack shelter, reside in congregate living settings, or lack regular access to basic hygiene supplies may be at higher risk for exposure and transmission of COVID-19 (Devakumar et al., 2020; Tsai & Wilson, 2020). Given the increased prevalence of homelessness for lesbian, gay, bisexual, and transgender (LGBT) adolescents compared to their heterosexual counterparts (Cochran et al., 2002), persons with non-dominant sexual and gender identities additionally may be at greater risk. POCI may be disproportionately vulnerable to COVID-19 exposure because of greater rates of existing medical and mental health conditions. Higher rates of hypertension in African American and Black individuals (Go et al., 2014) and diabetes in South Asian populations (Unnikrishnan et al., 2018) have been identified as pre-existing health conditions that negatively affect the prognosis of COVID-19 treatment (Centers for Disease Control and Prevention, 2020). Undocumented persons may also face unique challenges because of fears associated with seeking medical assistance. Consequently, by the time undocumented persons arrive to medical settings, the disease has reached an advanced stage and physical health is significantly compromised (Devakumar et al., 2020).

Effects of Racial Discrimination on Wellness
Racial microaggressions are the everyday slights, insults, invalidations, and offensive behaviors experienced by POCI through interpersonal verbal and nonverbal communication, media, educational curriculum, mascots, monuments, and other forms (Sue et al., 2007). Indeed, the experiences of racism, discrimination, and microaggressions faced by POCI negatively affect their mental and physical health (Alvarez et al., 2016; American Psychological Association, 2016) and increase their risk factors for developing mental and physical health problems (Carter, 2007; Carter et al., 2005; Clark et al., 1999; Harrell, 2000; Pieterse et al., 2012). Although many Indigenous, Latinx, and Asian populations face racial discrimination and suffer from race-based stress, African American and Black individuals are disproportionately affected (Chou et al., 2012). Experiencing racial discrimination has been linked to increased rates of depression in African Americans (Chou et al., 2012; Jones et al., 2007), Pacific Islanders (Allen et al., 2017), Indigenous women (Benoit et al., 2016), and Latinx populations (Araújo & Borrell, 2006; Chou et al., 2012; Pieterse et al., 2012). Indeed, ongoing experiences of racial discrimination have been described as resulting in a chronic state of “racial battle fatigue” that taxes the mental and emotional resources of people of color (Smith et al., 2011, p. 64).

In one study of 12 common mental health disorders, including major depressive disorder, dysthymic disorder, panic disorder, separation anxiety disorder, social anxiety, generalized anxiety, post-traumatic stress, alcohol abuse, drug use, attention deficient hyperactivity disorder, oppositional defiant disorder, and conduct disorder, using a national sample (N = 5,191), perceived discrimination was positively associated with each mental health diagnosis in African American and Afro-Caribbean adults (Rodriguez-Seijas et al., 2015). Perceived racial discrimination also has deleterious effects on Asian Americans’ wellness. Studies have consistently linked race-related stress and perceived discrimination in AAPIs to increased rates of psychological distress, suicidal ideation, anxiety, and depression (Gee et al., 2007; Hwang & Goto, 2008; Wei, Alvarez, et al., 2010). Additional studies have evidenced how the presence of race-based stress significantly and negatively correlates to feelings of self-esteem (Liang & Fassinger, 2008), social connectedness (Wei et al., 2012), and overall well-being (Iwamoto & Liu, 2010) in Asian American populations. The daily experiences of racial microaggressions, combined with the current political climate (Potok, 2017), represent a source of significant stress for POCI and may lead to racial trauma.

Racial trauma refers to the events or danger related to real or perceived experiences of racial discrimination (Carter, 2007). These experiences include threats of harm and injury, humiliating and shameful events, and witnessing harm to other POCI because of real or perceived racism (Carter, 2007). The effects of racial trauma parallel symptoms of other trauma-based disorders, including acute stress disorder and post-traumatic stress disorder. POCI may experience hypervigilance, avoidance, flashbacks, and nightmares related to the events of racial discrimination (Comas-Díaz et al., 2019) and somatic expressions, including headaches, heart palpitations (Comas-Díaz et al., 2019), dizziness, confusion, and difficulty concentrating (Hinton & Jalal, 2019). Healing race-based trauma requires counselors to consider the intersectional identities that uniquely influence experiences of oppression and discrimination for marginalized groups. Because POCI experience race-based stress throughout their lives (Gee & Verissimo, 2016) and the nature of discrimination lies within sociocultural contexts (Comas-Díaz et al., 2019), healing these racial wounds can be difficult.

Although facing the daily onslaught of microaggressions and racial discrimination clearly contributes to the presence of race-based stress and trauma across POCI, specific strategies to address each of these racial groups is beyond the purview of this article. The increased rates of sinophobic attitudes, behaviors, and racial slurs fueled by COVID-19 fears, internet activity, and media misinformation are specific stressors that may uniquely affect AAPI groups. The following sections outline the clinical implications for counseling AAPIs who face racial discrimination resulting from COVID-19 fears and the current sociopolitical climate.

Clinical Implications for Counseling Asian Americans and Pacific Islanders

In the United States, an ideology of White supremacy exists, which justifies policies and practices that maintain the subordination of people of color through social arrangements using power and White privilege (Huber & Soloranzo, 2015). Addressing disparities in racial wellness thus requires counselors to challenge these existing inequalities embedded in the current social zeitgeist. The combined fear of infectious disease, misrepresentation in media, and current sociopolitical climate have illuminated the importance of identifying culturally sensitive strategies to heal race-based trauma in AAPIs. Beginning from initial assessment and intake, counselors must consider how intersectional identities such as ethnicity, country of origin, affectional identity, gender identity, age, socioeconomic status, and other statuses influence the social positioning, experiences, and worldview of their AAPI clients. Counselors must additionally be prepared to navigate language barriers, undocumented status, and challenges related to health care access with cultural humility.

As counselors prepare to screen for race-based trauma, it becomes of paramount importance to consider how Southeast Asian and Chinese populations are more likely to report somatic complaints that differ from Eurocentric trauma symptoms, including difficulty sleeping, dizziness, difficulty concentrating, and physical complaints such as headaches, stomach problems, and chronic pain (Dreher et al., 2017; Grover & Ghosh, 2014; Hinton & Good, 2009; Hinton et al., 2018). As with all clients, counselors are called to reflect on how their own internalized biases and attitudes may compromise treatment effectiveness and to avoid imposing their values onto clients (American Counseling Association, 2014). The experiences of racial oppression and discrimination toward AAPIs are often overlooked because of the model minority stereotype that portrays Asian Americans as achieving high educational and societal success (Ocampo & Soodjinda, 2016). In reality, AAPIs face explicit experiences of racism and physical and emotional harassment related to accents and physical appearance (Choi & Lim, 2014; Qin et al., 2008). Counselors are thus encouraged to pursue their own counseling and engage in dialogue with supervisors, friends, and colleagues to identify and challenge the presence of implicit biases or preconceived notions held about AAPI groups. Counselors must consider ways to deliver treatment within the cultural settings in which clients feel most safe and comfortable (Helms et al., 2012) to effectively heal race-based trauma in AAPIs.

Decolonizing Trauma-Based Interventions
Constructs related to trauma, traumatic stress, and trauma-based interventions are largely embedded in European perspectives and historically have failed to consider the influence of intersectional identities in trauma treatment and recovery (L. S. Brown, 2008; Hernández-Wolfe, 2013; Mattar, 2011). The importance of contextualizing trauma-based interventions when working with people of color has been identified in the literature (Helms et al., 2012), and the extant literature on trauma-based interventions has identified a lack of cultural relevance for most POCI (Bryant-Davis & Ocampo, 2006; Hinton & Good, 2016; Hinton & Lewis-Fernández, 2011). Many existing theories and trauma-based interventions may therefore lack cultural relevance for AAPI groups. Counselors must therefore decolonize trauma-based interventions and consider whether trauma treatments are culturally sensitive and appropriate for Asians and Asian Americans who present with COVID-19–related trauma symptoms.

Healing Race-Based Trauma in AAPIs
When racial discrimination occurs, people of color, including AAPIs, may experience rumination about the situation and negative self-evaluation because of lack of action (Shelton et al., 2006; Sue et al., 2007). POCI who respond passively, ignore, or do not stand up for themselves may experience greater feelings of helplessness or hopelessness, or be more likely to endorse the fatalistic belief that racism is normative and must be accepted (Williams & Williams-Morris, 2000). For many AAPI individuals, facing sinophobic attitudes and behaviors may result in problematic outcomes. Because Asian cultures tend to discourage conflict and demonstrate a preference for maintaining interpersonal harmony (Ting-Toomey et al., 2000; Yum, 1988), AAPIs may be more likely to employ the use of indirect and subtle approaches (Lee et al., 2012). Compared to other racial groups, AAPIs may be more likely to use maladaptive coping strategies linked to poorer mental health outcomes, including avoidance (Edwards & Romero, 2008), internalization of events in ways that lead to self-blame and self-criticism, social isolation (Wei, Heppner, et al., 2010), and substance use (Pokhrel & Herzog, 2014).

Promoting Mindfulness and Self-Compassion
Increasing self-compassion through mindfulness and compassion meditation represents a culturally sensitive strategy to heal race-based trauma in AAPIs. Originating from Buddhist psychology, compassion meditation helps people release feelings of anger and decrease suffering by cultivating compassion and unconditional regard toward the self and others (Germer & Neff, 2015). Increasing self-compassion may decrease feelings of guilt and shame following instances of racial discrimination by fostering feelings of love and kindness toward oneself. As an emerging clinical intervention, compassion meditation has yielded positive results in decreasing experiences of shame and self-criticism (Gilbert & Procter, 2006; Kuyken et al., 2010), reducing symptoms of depression (Graser et al., 2016; Kearney, 2015), and promoting overall psychological wellness (Hofmann et al., 2011; Shonin et al., 2015). Notably, compassion-based mindfulness interventions show promise as a culturally sensitive strategy to heal race-based trauma (Au et al., 2017; Germer & Neff, 2015; Kearney, 2015). Mindfulness interventions such as compassion meditation may additionally address societal limitations related to health care access and financial barriers. Compassion meditation can be practiced anywhere and does not require expensive books, seminars, or the use of tools.

Counselors can support AAPI clients who present with race-based trauma to cultivate self-compassion by encouraging them to focus on their immediate needs, without judgment, in the present. According to Germer and Neff (2015), the main question when cultivating self-compassion is “What do I need now?” (p. 50). This inquiry is intended to help people connect with their emotional wants, needs, and desires, in the moment, without judgment. Turning awareness toward oneself may illuminate the need for community support or peer support, or point to a physical need, such as fatigue or hunger. Counselors may promote self-compassion through the meditative Hawaiian prayer, Ho’oponopono. Clients may practice the Ho’oponopono meditation by directing four statements toward themselves: “I love you,” “I’m sorry,” “Thank you,” and “Forgive me.” Counselors may help clients begin to heal race-based trauma by empowering them to reflect on their phenomenological experiences as each statement was made. Counselors are encouraged to engage in their own experiences of mindfulness and self-compassion to deepen their understanding of how to modify the practices for clients (Germer & Neff, 2015).

Counselors may empower AAPI clients facing racial discrimination by providing psychoeducation about microinterventions and creating opportunities for behavioral rehearsal using role plays. Microinterventions are everyday words, deeds, or actions that communicate validation of experiential reality, value as a person, affirmation of racial or group identity, support and encouragement, and reassurance that the receiver is not alone (Sue et al., 2019). Microinterventions seek to empower POCI, White allies, and bystanders to confront and educate perpetrators of microaggressions and have four major strategic goals: making the “invisible” visible, disarming the microaggression, educating the perpetrator, and seeking external reinforcement or support (Sue et al., 2019). Before engaging in microinterventions, it is important to consider the possible positive and negative consequences that may occur. Counselors should discourage AAPI clients from addressing microaggressions when doing so may threaten their physical safety. Engaging in microinterventions in scenarios where a strong power differential exists, such as in workplace or education settings, also requires special consideration (Sue et al., 2019). A full description of each microintervention strategy, goal, objective, rationale, and tactic are beyond the purview of this article, although a few examples for practical application for AAPI clients in counseling are provided below.

Making the “Invisible” Visible. Making the “invisible” visible represents an important component of healing race-based trauma. The first step to liberation necessitates naming the innuendo because it provides language for POCI to describe their experiences and seek mutual validation (Freire, 1970). Counselors may empower AAPI clients to make the “invisible” visible by bringing the microaggression to the perpetrator’s awareness, indicating to the perpetrator that they have spoken or behaved in an offensive way, or forcing the perpetrator to consider the impact and meaning of what has occurred (Sue et al., 2019). These tactics serve to undermine the metacognition, make the metacognition explicit, and broaden the ascribed trait (Sue et al., 2019) and may be helpful for AAPIs who experience race-based discrimination. For example, an Asian American who is accused of having “Kung-Flu” in public may make the metacognition explicit by stating, “You assume I am contagious because of the way I look.” In the same scenario, ascribed traits can be broadened and clarification can be obtained by using statements such as “Anyone can become infected with COVID-19; it is not solely limited to Asians,” and “Are you worried I will get you sick?” Each of these responses are intended to directly identify and address the microaggression while bringing awareness of the metacognition to the perpetrator.

Disarming the Microaggression. Disarming the microaggression may be employed to stop or deflect the microaggression, force the perpetrator to consider their actions, and communicate disagreement (Sue et al., 2019). Helpful tactics AAPIs can use to disarm microaggressions include expressing disagreement, using an exclamation, and stating values and setting limits (Sue et al. 2019). For example, a young Asian American who sees denigrating comments about AAPI individuals on a social media page may respond with the exclamation, “Ouch!” According to Aguilar (2006), this simple exclamation communicates that something offensive has occurred and forces the person to consider the impact and meaning of their behavior. In the same situation, AAPIs may state values and set limits by responding to an offensive comment with, “I have always been respectful of your values and recognize how people are free to hold different attitudes, but I hope you see that what you have written is offensive.”

Educate the Offender. Although it is inappropriate to ask POCI to educate and confront perpetrators, as it exclusively puts the onus of change onto the marginalized person, educating the offender may represent an important strategy to affect societal change. One powerful objective is to facilitate an enlightening conversation that indicates how what has occurred was offensive (Sue et al., 2019). This tactic helps perpetrators differentiate between their intent and the resulting impact (Sue et al., 2019). Because many people become defensive and shift from action to intention when a microaggression is pointed out (Sue, 2015), differentiating between good intent and harmful impact represents a powerful educational strategy (Sue et al., 2019). For example, a Chinese woman may hear COVID-19 incorrectly termed “the Chinese virus” in a conversation among colleagues. In this scenario, she may choose to engage in an enlightening dialogue to educate the offender about how the term “Chinese virus” perpetuates offensive sinophobic attitudes. A helpful conversation starter might be, “I know you may not realize this, but referring to COVID-19 as ‘the Chinese virus’ denigrates Asian individuals and is offensive.” In the same situation, it may additionally be helpful to point out how the term “Chinese virus” violates the WHO (2015) best practices policy for naming new human infectious diseases.

Seek External Reinforcement or Support. The final microintervention is aimed at the promotion of regular self-care, ensuring optimal levels of functioning, and communicating to perpetrators that bigoted behavior is unacceptable (Sue et al., 2019). Self-care and promoting wellness can be employed by pursuing counseling, reporting sinophobic behaviors to appropriate authorities, and seeking the support of one’s spiritual or religious communities (Sue et al., 2019). An increasing number of AAPIs are reaching out to crisis support hotlines. As of March 2020, approximately 13% of AAPIs had contacted crisis text lines compared to 5% of other U.S. callers, respectively (Filbin, 2020). Similar to other POCI, the presence of social support and collective gathering represents an effective coping strategy for Asian Americans (Wei, Alvarez, et al., 2010; Wei et al., 2012; Yoo & Lee, 2005). Indeed, seeking support represents an important strategy AAPIs employ to preserve mental health.

Cultural Proverbs and Analogies
Incorporating proverbs and analogies embedded in AAPI traditions are culturally sensitive strategies to empower clients and strengthen their ethnic identity. Cultural metaphors and stories may additionally strengthen the therapeutic alliance, as AAPI clients may feel their counselor understands and appreciates their cultural background (Hinton & Jalal, 2019). Strong identification with one’s ethnic group promotes wellness and serves as a protective factor in AAPI groups (Iwamoto & Liu, 2010) and Filipino Americans (Mossakowski, 2003). Counselors can empower clients to promote ethnic pride and increase cultural commitment by using proverbs and stories from client culture in counseling. Guiding AAPI clients to embrace their rich and important tradition of knowledge may promote self-esteem and decrease negative affect (Hinton & Jalal, 2019).

Two popular examples of Filipino proverbs may be helpful to promote the importance of social support and cultivate compassion when perpetrators are reluctant to recognize how their behaviors are offensive. A Filipino proverb posits, “A broom is sturdy because it is tightly bound” (in Tagalog, “Matibay ang walis, palibhasa’y magkabigkis”). This message aligns with a collectivistic mentality that people are stronger when standing together. Another Filipino proverb suggests, “It is hard to wake someone up who is pretending to be asleep” (in Tagalog, “Mahirap gisingin ang nagtutulog-tulugan”). This saying cultivates empathy and compassion for perpetrators of microaggressions and sinophobic behavior by reminding clients how it is difficult to educate others when they are not ready or willing to expand their worldviews. Similarly, a Chinese proverb states, “If you are planning for a year, sow rice; if you are planning for a decade, plant trees; if you are planning for a lifetime, educate people.” This saying may motivate clients to engage in dialogue with the people in their lives who have committed hurtful microaggressions. Because AAPI clients tend to terminate counseling at earlier rates compared to other racial groups (Sue & Sue, 2016), counselors can use appropriate cultural analogies to demystify the counseling process. For example, counselors may liken the therapeutic process to cooking a traditional noodle dish (Hinton & Jalal, 2019). Analogous to preparing japchae in Korean culture, pancit palabok in Filipino kitchens, or the Chinese dish zhajiangmian, healing from race-based trauma is a process that necessitates patience, creativity, commitment, and flexibility.

The U.S. Surgeon General has recognized how racial and ethnic health disparities are strongly linked to the presence of systemic and ongoing cultural racism (U.S. Department of Health and Human Services, 2000). Counselors who hold dominant social identities (e.g., White, male, heterosexual) are uniquely positioned to use their power and privilege to advocate on behalf of AAPI clients, other POCI, and other marginalized groups by challenging systemic forms of oppression. Indeed, endorsing positive attitudes about diversity (Broido, 2000) and consciously committing to disrupting the cycle of injustice (Waters, 2010) are foundational characteristics of White allies, who seek to end disparity and work to promote the rights of oppressed groups (K. T. Brown & Ostrove, 2013). According to Sue and colleagues (2019), allies actively commit to engaging in actions that dismantle individual and institutional beliefs, practices, and policies that have created barriers for people of color.

AAPIs are facing greater rates of racial discrimination, harassment, violence, sinophobic attitudes, and racial slurs because of fears related to COVID-19 and the current sociopolitical climate. Counselors may help AAPI clients heal race-based trauma through the use of culturally adapted strategies such as promoting mindfulness and self-compassion, employing the use of microinterventions, and incorporating culturally appropriate proverbs and analogies in counseling treatment. Counselors are encouraged to adopt strategies to help AAPIs heal from race-based trauma because experiences of racial discrimination, microaggressions, and sinophobic behaviors are not limited to the current pandemic and instead represent longstanding forms of oppression embedded in American history and culture. AAPIs faced marginalization and racial discrimination before the presence of COVID-19 and will likely continue to experience race-related stress long after the discovery of a vaccination. Just as COVID-19 has illuminated disparities within medical, institutional, and political systems, it has also uncovered the enduring ethnocentric attitudes of many Americans. The proliferation of ongoing discrimination of all racial, ethnic, and marginalized groups is representative of a more insidious form of societal sickness.

Limitations and Future Areas of Research
Although the present article outlines the culturally alert strategies for healing race-based trauma among AAPIs, other marginalized groups face unique challenges related to the unprecedented effects of COVID-19 on social, institutional, and political levels. The deleterious effects of homelessness, social isolation, witnessing of real or perceived racial discrimination or violence, and issues related to LGBTQ individuals because of COVID-19–related issues and policies remain of paramount importance but were not explicitly discussed in this article. Future areas of research may examine the effects of racial discrimination during public health crises and other global events (Wen et al., 2020). Additionally, the ways in which AAPI groups respond to instances of racial discrimination and sinophobia because of COVID-19–related stress remain largely unknown. The manifestation of intergenerational trauma on AAPI families related to COVID-19 also represents an important area of future study. Finally, the national and global effects of COVID-19 on the mental health of diverse groups represents an essential topic of future study.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.


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Stacey Diane Arañez Litam, PhD, NCC, CCMHC, LPCC, is an assistant professor of counselor education at Cleveland State University. Correspondence may be addressed to Stacey Litam, Cleveland State University, 2121 Euclid Avenue, Julka Hall 275, Cleveland, OH 44115, s.litam@csuohio.edu.

Attachment, Ego Resilience, Emerging Adulthood, Social Resources, and Well-Being Among Traditional-Aged College Students

Joel A. Lane


To improve conceptualizations of college student mental health, the present study (N = 538) compared predictors of well-being that comprise both well-established counseling theories (e.g., attachment) and newer models specific to the life experience of the millennial generation and Generation Z. Predictors included internal resources (i.e., attachment security, ego resilience), emerging adulthood identification, and social resources (i.e., social support, social media usage). Each variable set predicted significant variance. The emerging adulthood and social media variables accounted for approximately 7% of variance in both psychological well-being and life satisfaction. Identifying emerging adulthood as a time of negativity and instability was the second strongest predictor of psychological well-being, while identifying emerging adulthood as a time of experimentation and possibilities was the second biggest predictor of life satisfaction. Implications for conceptualizing and treating today’s students are discussed.

Keywords: college counseling, emerging adulthood, social media, attachment, social support

In recent years, higher education personnel have noticed declines in college student emotional health and corresponding increases in stress, depression, and anxiety (Watkins et al., 2012). The rates of students exhibiting frequent anxiety and depression symptoms have nearly doubled over a 30-year period and are now two to three times higher than those of the general population (American College Health Association [ACHA], 2015). Administrators have also described corresponding changes in college counseling services, especially regarding the increased need for crisis intervention and triage services (Watkins et al., 2012).

These trends roughly correspond to the millennial generation and Generation Z entering college. The societal forces that characterize these generational cohorts, including the proliferation of social media (Ellison et al., 2007; McCay-Peet & Quan-Haase, 2017) and increases in parental involvement and corresponding decreases in perceptions of college student maturity and autonomy (Watkins et al., 2012), seem to have substantially altered the psychosocial trajectories for today’s traditional-aged college populations (Arnett, 2004, 2016). The counseling profession has wrestled with how best to respond to these trends, and in many cases has relied on conceptual frameworks and theories of psychosocial development created long before the emergence of the millennial generation. It seems timely to attempt to develop a framework for mental health and well-being during the college years that incorporates theories specific to present generations of traditional-aged college students with more well-established theories of development. Such is the purpose of the present study, in which the contributions to college student well-being of attachment security (Bowlby, 1969/1997), ego resilience (Block & Block, 1980), and social support are integrated with and compared to the theory of emerging adulthood (Arnett, 2004), a conceptualization of psychosocial development occurring from the late teens through the 20s for contemporary generations.

Attachment and Ego Resilience

It is generally accepted that the constructs of attachment security and ego resilience play important roles in college student mental health and well-being (e.g., Lane, 2015; Taylor et al., 2014). According to Bowlby (1969/1997), the quality of our earliest interactions with caregivers provides us with relational templates, or types of attachment, that influence self-worth and interpersonal functioning throughout the life span. Ego resilience is a personality trait reflecting our ability to adapt and thrive amid stress and transition (Block & Block, 1980; Taylor et al., 2014). In the present study, attachment and ego resilience are conceptualized as internal resources because they are instilled early in life, relatively stable over time, and influential to mental health during the college years (Lane, 2016; Lane et al., 2017; Taylor et al., 2014).

Attachment and ego resilience also similarly impact functioning in times of challenge. With secure attachment, individuals are more likely to believe themselves capable of handling adversity and that others can be called upon in times of need (Brennan et al., 1998), presumably because of the consistent responsiveness of their caregivers earlier in life. Conversely, insecure attachment can lead individuals to doubt their own capabilities (i.e., attachment anxiety) or the intentions of others to provide them with support (i.e., attachment avoidance) in times of need. These internalized beliefs can lead to problematic outcomes during distressing situations (Wei et al., 2007), including maladaptive interpersonal dependence or isolation and a heightened focus on the distress (Brennan et al., 1998). Similarly, individuals high in ego resilience are generally able to respond to stressful situations with flexibility and an assortment of healthy coping behaviors (Taylor et al., 2014). Conversely, individuals low in ego resilience may lack the diversity of healthy coping strategies necessary to effectively persevere through a range of life challenges, and they may be prone to giving up when frustrated (Block & Block, 1980). Thus, individuals with attachment insecurity and low ego resilience are at an increased risk of accumulating stress during stressful situations rather than persevering through them (Brennan et al., 1998), which is a likely explanation for the associations of each construct with depression and anxiety symptoms (Taylor et al., 2014).

This latter point is especially important in the context of the present study. The college experience contains numerous life and role transitions, including leaving home, establishing independence, reconstructing social support networks, and developing professional goals (Lane, 2015). Each of these transitions pose opportunities for students high in internal resources to thrive and risks for those who are low in internal resources to accumulate stress and negative mental health symptoms (Lane, 2015). Accordingly, internal resources are conceptualized as the first set of constructs in the present model. That is, they seem to provide a foundation for college student mental health and well-being and perhaps do so by contributing to other potentially relevant aspects of well-being, such as identification with emerging adulthood (Schnyders & Lane, 2018) and social support (Galambos et al., 2006).

Emerging Adulthood

Although attachment and ego resilience have long been considered contributors to college student mental health and well-being, many of the aforementioned factors involved in declining mental health trajectories comprise social forces unique to present-day young adults. Emerging adulthood (Arnett, 2004) is a theory that describes the effects of such factors on psychosocial functioning between the ages of 18 and 29. Specifically, it suggests that this age range now represents a period of life distinct from both adolescence and adulthood. The theory describes several dimensions that are representative of the present-day emerging adult experience, including a prolonged period of identity exploration (i.e., using the emerging adulthood years to consider and audition preferences regarding career, worldviews, romantic relationships, and interpersonal characteristics), significant demographic and relational instability (e.g., increased likelihood of multiple residence changes with respect to previous generations, causing disruptions in social groups), subjectively feeling in between adolescence and adulthood, and idealistic thinking about future possibilities (Arnett, 2004). These dimensions suggest that emerging adulthood is a complex phenomenon with significant individual variation: One’s degree of identification with each dimension can shape their relative satisfaction with the overall emerging adulthood experience (Baggio et al., 2015). Moreover, some evidence suggests that parental attachment quality predicts one’s identification with the various themes of emerging adulthood (Schnyders & Lane, 2018).

Emerging adulthood theory has several implications in the context of college student well-being. First, life transition is a salient theme of emerging adulthood, given that the late teens and 20s are a time of leaving the parental household, creating new attachment and support networks, entering and persisting through college (for many emerging adults), and entering the world of work (Arnett, 2004). These transitions can leave emerging adults vulnerable to distress (Lane et al., 2017) and are central features of the college student experience. Second, emerging adulthood suggests that present traditional-aged college students are at an earlier stage of psychosocial development than prior generations, even though expectations placed on them have remained stable (Arnett, 2004). Thus, emerging adult college students are still expected to navigate the many transitions of the college experience regardless of whether or not they have developed the necessary maturity and life skills. Finally, the emerging adulthood years constitute a high degree of risk-taking behaviors, impulsivity, and psychiatric risk (Arnett, 2004; Baggio et al., 2015). That is, not only is emerging adulthood a time of vulnerability to stress, but also a time of elevated risk for maladaptive stress responses. Thus, in the context of the present study, it is possible that the emerging adult experience uniquely contributes to mental health and well-being with respect to the contribution of internal resources.

Social Resources

Like interpersonal resources and emerging adulthood, social support is a construct with implications for mental health. The degree to which an individual feels supported by their close relationships mitigates distress during stressful situations (Sarason et al., 1991). Individuals who are satisfied with their social support also report less depression, anxiety, and loneliness, and enhanced well-being compared to those low in social support (Galambos et al., 2006).

The aforementioned societal changes impacting emerging adulthood also have implications for college student social support. Today’s emerging adult social support networks have grown in complexity as psychosocial developmental trajectories have continued to evolve (Arnett, 2004) and social media has become an increasingly ingrained aspect of everyday life. These changes necessitate reconsideration of the construct of social support in the 21st century. That is, what are the implications for social support when interpersonal contact is increasingly conducted electronically? Is it possible for one to derive the benefits of social support from social media interactions? To address these questions, Manago et al. (2012) asked a sample of college students to respond to various support-related questions while browsing Facebook. Participants were able to use Facebook to meet certain intimacy needs, especially that of emotional disclosure, and the size of one’s Facebook friends list was positively associated with perceived social support and life satisfaction. Others have suggested that social media sites provide social capital and facilitate sustained connection with potentially beneficial relationships (Ellison et al., 2007). In light of these ideas, the present study conceptualizes social resources to include both social support and social media usage. Assessing the degree to which each construct impacts college student mental health and well-being is important given the ubiquity of social media on college campuses and the current disagreement among scholars regarding its benefits (Manago et al., 2012) and drawbacks (Twenge, 2013). Given that social support seems to facilitate the contributions of internal resources to mental health (Taylor et al., 2014) and emerging adulthood contributes to increasingly complex social networks (Arnett, 2004), social resources are conceptualized as a third level of constructs in the present model, after internal resources and emerging adulthood identification.

Present Study

The present study was designed to address several literature gaps concerning college student mental health and well-being. First, it combines several disparate threads of related research by testing a model including internal resources (i.e., attachment security and ego resilience), identification with the dimensions of emerging adulthood, and social resources (i.e., social support and social media usage). Although some research has examined the additive impact of more than one of these sets of constructs together (e.g., attachment and social support), no existing research has examined all three collectively. Second, the present study examined the mental health implications of emerging adulthood and social media usage: two constructs that are the result of 21st century societal forces. A primary hypothesis of the study was that each predictor variable set would explain unique and additive variance for two characteristics of college student mental health (i.e., psychological well-being [PWB] and life satisfaction). A secondary hypothesis was that emerging adulthood identification and social media usage would predict unique variance in each outcome variable even after accounting for the effects of all other predictor variables in the model.


Participants and Procedure

Participants in this IRB-approved study were traditional-aged undergraduate students from a large, public university in a metropolitan area of the Pacific Northwest. Participants were recruited via a recruitment email sent to a random sample of students meeting the inclusion criteria (i.e., 18 to 25 years old and enrolled as a full-time undergraduate student). An a priori power analysis was conducted to determine appropriate sample size (Faul et al., 2007). Given the large number of variables in the model and the fact that Hypothesis 2 was based on semipartial correlations, a small-to-medium effect size was selected (f 2 = .08). Results suggested an ideal sample size of approximately 400 participants. Assuming an approximate 10% response rate (Manfreda et al., 2008), recruitment emails were sent to 4,000 undergraduates.

The recruitment email contained a link to an online survey containing all demographic and study variable items. Surveys were received from 616 undergraduates (15.4% response rate). Data were treated according to the recommendations for multivariate analysis by Meyers et al. (2013). That is, 56 cases (9.1%) were removed because they contained missing data on at least 50% of the items. An additional 17 cases (2.8%) were removed for indicating that they were no longer paying attention at the midpoint of the survey. The remaining missing values were replaced with their respective item mean because no item was missing more than seven cases (1.3%) and no variable contained more than two missing items for any remaining participant. Data were screened for multivariate outliers using Mahalanobis distance, resulting in the removal of five (0.9%) participants. Thus, the study sample consisted of 538 participants.

The study sample had a mean age of 21.72 years (SD = 2.05) and was predominantly female (n = 378, 70.3%), while other participants identified as male (n = 142, 26.4%) or other (n = 16, 3.0%), and two participants declined to answer. The sample was racially diverse, as 341 (63.4%) participants identified as White, 64 (11.9%) as Latinx, 63 (11.7%) as Asian or Pacific Islander, 14 (2.6%) as Black or African American, 11 (2.0%) as Arab American or Middle Eastern, eight (1.5%) as Native American, 27 (5.0%) as multiracial, and seven (1.3%) as other, while three participants declined to answer.


Attachment security. As the first internal resources variable, attachment security was measured using the 12-item Experiences in Close Relationship Scale-Short Form (ECR-S; Wei et al., 2007). The items are evenly divided into two subscales: Attachment Anxiety (e.g., “I need a lot of reassurance that I am loved by my partner”) and Attachment Avoidance (e.g., “I am nervous when partners get too close to me”). Items are rated on a 7-point Likert scale. Scores were summed, with higher scores indicating higher attachment insecurity for each dimension. Internal consistencies in the present sample (α = .78 for attachment anxiety, α = .80 for attachment avoidance) mirrored those reported by the ECR-S authors (α = .77 and α = .78, respectively).

Ego resilience. Ego resilience served as the other internal resources variable. It was measured using an 11-item version of Block and Block’s (1980) Ego-Resiliency Scale (Taylor et al., 2014). Items (e.g., “I can bounce back and recover after a stressful or bad experience”) are rated on a Likert scale ranging from one (most undescriptive of me) to nine (most descriptive of me). Higher total scores indicate higher ego resilience. The 11-item version has demonstrated internal consistencies ranging from .63 to .81 across multiple time points with a sample of emerging adults (Taylor et al., 2014). Internal consistency in the present sample was .73.

Emerging adulthood. The second level of predictor variables comprised dimensions of emerging adulthood. Identification with emerging adulthood dimensions was assessed using the 8-item Inventory of Dimensions of Emerging Adulthood (IDEA-8; Baggio et al., 2015). The items are evenly divided into four subscales (i.e., Experimentation/Possibilities, Negativity/Instability, Identity Exploration, and Feeling In Between [adolescence and adulthood]) that each represent dimensions of emerging adult theory (Arnett, 2004). Participants rate the degree to which various statements represent the present time in their lives (e.g., “this is a time of deciding on your own beliefs and values”) on a 4-point scale (1 = strongly disagree, 4 = strongly agree). Scores for each subscale are summed to indicate how participants feel each dimension characterizes their emerging adulthood experience. The IDEA-8 subscales demonstrate internal consistencies ranging from .66 to .76 (Baggio et al., 2015), mirroring the range
found in the present sample (α = .69 to α = .77).

Social support. Social support served as the first social resources variable. It was measured using the 6-item Subjective Social Support subscale of the Duke Social Support Index (Blazer et al., 1990). Items (e.g., “Can you talk about your deepest problems with at least some of your family and friends?”) are rated on a 5-point scale (1 = none of the time, 5 = all of the time), with higher scores indicating higher perceived social support. Internal consistency in the present sample was .85, mirroring estimates found in prior studies (α = .82; Hawley et al., 2014).

Facebook usage. The other social resources variable was social media usage, measured using the 8-item Facebook Intensity Scale (FIS; Ellison et al., 2007). Although numerous social media platforms are popular among college students, developers of social media usage instruments have focused on Facebook. Given its recognizability and ubiquity, it remains the best proxy for assessing overall social media usage (Ortiz-Ospina, 2019). The first FIS item asks participants to approximate their number of Facebook “friends,” while the second item asks them to approximate time spent on Facebook each day. The remaining items ask participants to rate their agreement with various items assessing the importance of Facebook in their lives (e.g., “Facebook has become a part of my daily routine”). Items are first standardized and then summed to create an index of Facebook usage. The FIS authors reported strong convergent validity and internal consistency (α = .83), mirroring that found in the present sample (α = .87).

College student mental health. Operationalizing mental health is challenging given its many existing conceptualizations. Some authors have argued that mental health and mental illness are separate constructs entirely (e.g., Lent, 2004). Lent (2004) suggested that a complete understanding of mental health incorporates both PWB and subjective well-being (i.e., happiness) and added that subjective well-being is best conceptualized as a higher-order outcome of PWB. Others have argued that PWB and depression are opposite ends of the same construct (Bech et al., 2003), suggesting that PWB instruments also measure depressive affect and vice versa. Collectively, and in conjunction with the focus on depressive symptoms in the aforementioned college student mental health research, it seems useful to conceptualize mental health using indices of PWB and life satisfaction (Lent, 2004).

Psychological well-being. PWB was measured using the 5-item World Health Organization-Five Well-Being Index (WHO-5; Bech et al., 2003). Each item is a positively worded self-statement measuring the absence of various symptoms of depression (e.g., “I have felt calm and relaxed”). Because of its ability to measure both well-being and depression, it was selected as an ideal candidate for the present study. The presence of each statement over a 2-week period is rated on a 6-point scale (0 = not present,
5 = constantly present). Scores are multiplied by four to create a 0–100 scale, with higher scores indicating higher PWB, and scores below 28 indicating clinical depression (Bech et al., 2003). The authors reported strong evidence for reliability (α = .82) and validity. In the present sample, internal consistency was .81.

Life satisfaction. Life satisfaction was measured using the Satisfaction with Life Scale (SWLS; Diener et al., 1985). Participants rate agreement with five items (e.g., “In most ways my life is close to my ideal”) on a 7-point scale (1 = strongly disagree, 7 = strongly agree). Internal consistency in both the validation study and present sample was .87.


Table 1 presents the descriptive statistics and intercorrelations for all study variables. With the exception of the emerging adult feeling in between variable, all variables were significantly correlated with each of the outcome variables. Significant correlations ranged from small to large for both PWB (r = .12, p < .05 for Facebook usage and r = .44, p < .001 for ego resilience) and life satisfaction (r = .12, p < .01 for identity exploration and r = .50, p < .001 for social support). Also, the outcome variables were significantly associated with three emerging adulthood variables in different directions. That is, they were positively correlated with experimentation/possibilities and identity exploration, and they were negatively and moderately correlated with negativity/instability; however, neither outcome variable was significantly associated with the feeling in between variable.

To reduce the possibility of confounds in the regression results, several potential covariates were tested for their relatedness to the outcome variables. Based on prior research, age, gender, and race were tested (Galambos et al., 2006; Schnyders & Lane, 2018). Gender and race were dummy coded so that a) 0 = non-woman (i.e., man or other) and 1 = woman, and b) 0 = non-White and 1 = White. Significant differences were present in the Satisfaction with Life Scale scores on the basis of gender: t(537) = -2.841, p < .01. The mean life satisfaction score for women in the sample was 1.91 points higher than for non-women. Thus, all subsequent analyses controlled for the effects of gender. No other significant associations involving the potential covariates were present.


Table 1

Pearson Intercorrelations Among Study Variables


Variables Intercorrelations
   M     SD 1 2 3 4 5 6 7 8 9 10
  1. AAn. 23.42 7.28       –
  2. AAv. 17.03 6.76      .07      –
  3. ER 69.10 11.94     -.33**   -.08      –
  4. EP  7.08 1.16     -.17**   -.04    .24**    –
   5. NI 6.90 1.24      .20**     .06   -.25** -.06    –
  6. IE 6.80 1.34     -.05    .04    .12*  .38**  .07     –
  7. IB 6.83 1.38      .06    .06   -.01  .22**  .12*   .41*   –
  8. SS 21.98 4.27     -.25**   -.27**    .32**  .21** -.19**   .07 .05   –
  9. FB 21.75 8.72      .13*   -.11*   -.05  .08 -.02   .08 .16** .14*   –
10. PWB 55.35 18.72     -.27**   -.14*    .44**  .32** -.34**  .16**  .03 .40** .12*   –
11. LS 21.72 7.21     -.25**   -.25**    .39**  .36** -.30**  .12* -.02 .50** .14* .61**

Note. N = 538. AAn. = attachment anxiety; AAv. = attachment avoidance; ER = ego resilience; EP = experimentation/possibilities; NI = negativity/instability; IE = identity exploration; IB = feeling in between; SS = social support; FB = Facebook usage; PWB = psychological well-being; LS = life satisfaction.
*p < .05. **p < .001



Hypothesis 1 predicted that internal resources, emerging adulthood identification, and social resources would each predict unique and additive variance in each outcome variable. Thus, two hierarchical regression analyses were conducted (one with PWB as the outcome variable and one with life satisfaction as the outcome). Each set of predictors was entered as an individual level in the hierarchical regression. Table 2 presents the results of these analyses. As can be seen in Table 2, Hypothesis 1 was fully supported. Each predictor variable set predicted significant additive variance in each outcome variable after accounting for the preceding predictor variable sets in the model. It is also useful to note that the social resources variables predicted over twice as much additive variance in life satisfaction (∆R2 = .08, p < .001) compared to that of PWB (∆R2 = .03, p < .001). The model accounted for 36% of the variance in PWB and 41% of the variance in life satisfaction.


Table 2


Summary of Hierarchical Regression Analyses Predicting PWB and Life Satisfaction

Step and Variable

∆R2 ∆F β t rsp
Outcome variable: PWB
Step 1 – Internal resources .22 38.619***
Attachment anxiety -.14         -3.438**   -.07*
Attachment avoidance -.09         -2.308* -.03
Ego resilience  .40          9.685***       .23***
Step 2 – Emerging adulthood .09   8.259***
Experimentation/possibilities  .19          4.677***       .14***
Negativity/instability -.23         -6.177***      -.20***
Identity exploration  .06          1.403  .05
Feeling in between  .00          0.03 -.02
Step 3 – Social resources .03   1.681***
Social support  .19          4.679***       .16***
Facebook usage  .09          2.361*   .08*
Outcome variable: Life satisfaction
Step 1 – Internal resources .22 32.966***
Attachment anxiety -.12         -2.960** -.03
Attachment avoidance -.20         -5.185***    -.11**
Ego resilience  .36          8.711***       .17***
Step 2 – Emerging adulthood .09   8.131***
Experimentation/possibilities  .26          6.571***       .20***
Negativity/instability -.19         -5.139***      -.15***
Identity exploration  .01          0.304  .02
Feeling in between -.05         -1.273  -.07*
Step 3 – Social resources .08   4.872***
Social support  .31          8.138***       .27***
Facebook usage  .08          2.176*    .07*

Note. N = 538. Results control for the effects of gender. rsp = semipartial correlation. rsp is reported for the
last step in each model.
* p < .05, ** p < .01, *** p < .001.


Hypothesis 2 predicted that the emerging adulthood variables and Facebook usage would each predict significant individual variance in each outcome variable after accounting for the effects of all other predictor variables. To test this hypothesis, semipartial correlations (rsp) were examined for all variables at the last step of the hierarchical regression (i.e., the step in which all variables are entered into the model). Semipartial correlations examine the unique variance explained by a single predictor after accounting for the collective variance explained by all other predictors (Meyers et al., 2013). As can be seen in Table 2, significant semipartial correlations predicting PWB included the negativity/instability (rsp = -.20, p < .001), experimentation/possibilities (rsp = .14, p < .001), and Facebook usage (rsp = .08, p < .05) variables. Of all the predictors of PWB in the model, negativity/instability made the second largest individual contribution. Of the predictors of life satisfaction, significant semipartial correlations included experimentation/possibilities (rsp = .20, p < .001), negativity/instability (rsp = -.15, p < .001), feeling in between (rsp = -.07, p < .05), and Facebook usage (rsp = .07, p < .05). The experimentation/possibilities variable made the second largest individual contribution to life satisfaction. However, because identity exploration was not significant for either outcome variable, and feeling in between was not significant for life satisfaction, Hypothesis 2 was only partially supported. Collectively, the emerging adulthood and Facebook variables accounted for 7.4% of unique variance in PWB and 7.1% of unique variance in life satisfaction.


The present findings yield several useful contributions. First, they bridge disparate threads of research by comparing the contributions of well-established mental health predictors with those of constructs unique to present-day college students, each of which contributed uniquely to college student mental health. Although many of the effects of the individual variables were small, the emerging adulthood and Facebook variables collectively explained roughly 7% of unique variance in the mental health variables over and above that explained by the more well-established constructs. As such, the findings are consistent with the assertion that constructs like attachment, ego resilience, and social support, while useful to conceptualizing college student mental health, may nevertheless be aided by also considering factors unique to 21st-century students.

The positive associations between Facebook usage and college student mental health are noteworthy, given the current disagreement regarding the impact of social media use. Contrary to concerns regarding social media overuse (e.g., Twenge, 2013), the present study found that Facebook usage positively predicted PWB and life satisfaction, albeit with a small effect. This was true even after controlling for other predictor variables, suggesting that Facebook provided a small but unique contribution to college student mental health. This finding supports the conclusions of Manago et al. (2012) that Facebook can fulfill certain social support needs for students. There may also be negative implications for societal reliance on social media use (e.g., Twenge, 2013), including its promotion of unhealthy comparison behaviors and cyberbullying. Nevertheless, the present findings and those of Manago et al. demonstrate the positive contributions of social media to college student mental health.

The significance of some of the emerging adulthood variables also warrants discussion. The degree to which participants identified with emerging adulthood being a period of experimentation and possibilities was positively associated with PWB and life satisfaction, while the degree to which they identified with emerging adulthood being a period of negativity and instability was negatively associated with PWB and life satisfaction. Moreover, identifying emerging adulthood as a time of feeling in between adolescence and adulthood was negatively associated with life satisfaction. Even after accounting for all other control and predictor variables, emerging adult instability was the second strongest predictor of PWB (after ego resilience), while emerging adult experimentation/possibilities was the second strongest predictor of life satisfaction (after social support). These findings add important context to prior empirical conclusions that emerging adulthood is associated with negative mental health (Baggio et al., 2015). That is, while each of the dimensions of emerging adulthood represents important developmental processes toward reaching adulthood (Arnett, 2004), only some of these dimensions (especially viewing emerging adulthood as a period of experimentation or instability) seem relevant to college student mental health. Additionally, feeling in between adolescence and adulthood was negatively associated with life satisfaction but unassociated with PWB. This finding underscores the complex contributions of emerging adulthood to college student mental health. Previous research has indicated that life satisfaction decreases during adolescence (Goldbeck et al., 2007). Accordingly, it is plausible that subjectively identifying the emerging adult years as feeling in between adolescence and adulthood results in life satisfaction trajectories that more closely mirror those of adolescence compared to emerging adults who feel less in between adolescence and adulthood. Although such conclusions require further validation, it nevertheless can help college counselors understand which factors of the emerging adult experience are relevant foci of clinical attention.

Implications for Counselors

The present results yield several useful insights that can aid mental health counselors who work with college-aged populations. Most prominently, counselors are encouraged to conceptualize their clients using a blend of foundational and contemporary models. Life for 21st-century college-aged individuals is unprecedentedly complex (Arnett, 2004; Kruisselbrink Flatt, 2013). It is important for college counselors to acknowledge this complexity, as doing so may represent an important form of cultural competence working with millennial generation and Generation Z individuals (Lane, 2015). Counselors are encouraged to utilize emerging adulthood theory when conceptualizing their clients, as this framework contains important departures from other identity development models. For example, counselors are likely to be more familiar with Erikson’s (1959/1994) framework than emerging adulthood theory. The former model suggests that identity development occurs during the teenage years, while the latter model asserts that identity development is a process that now extends well into the 20s (Arnett, 2004). Emerging adulthood theory also suggests that, as a result of this prolonged identity development process, traditional-aged college students are likely to temporarily exhibit heightened self-focus and idealistic thinking. Acknowledging these factors could facilitate a more empathic understanding of the behaviors that contribute to some counselors and scholars endorsing negative stereotypes against millennials and Generation Z individuals (Lane, 2015). Incorporating emerging adulthood theory could help college counselors be more mindful of the evolving nature of the transition to adulthood and its contributions to mental health.

The findings involving the social resources variables also have novel implications for counseling college students. Although social support has long been established as an important target for improving mental health, counselors are encouraged to acknowledge both the unprecedented complexity of emerging adult social support networks (Arnett, 2004) and also the ability of emerging adults to receive social support from face-to-face and electronic interactions (Manago et al., 2012). Accordingly, it is important to continue exploring the potential therapeutic applications of social media and other forms of technology. For example, an exciting direction in this regard is the growing use of informal support groups via social media (Manago et al., 2012), which exist for many counseling-relevant issues. Such groups provide a sense of community and help members remember that they are not alone in their struggles. Moreover, present mental health trajectories among college students have necessitated a shift in focus for many college counseling centers toward crisis intervention and outreach (Watkins et al., 2012). For many college counseling centers, social media remains an underutilized tool, despite the recent development of social media and text-based initiatives for each of these objectives (Evans et al., 2013). Such programs might be especially useful in today’s higher education climate in which symptom severity seems to be increasing while budgetary resources for college counseling centers are often stagnant or decreasing (American College Health Association, 2015; Watkins et al., 2012).


Several limitations in the present study warrant consideration. First, the results relied on a convenience sample, and it is impossible to know whether there are group differences between the 15.4% of invited college students who participated compared to those who did not. Second, the findings are correlational in nature, and the directionality of the relationships cannot be assured. Third, although the sample was racially diverse, it was predominantly female. Fourth, it should be noted that the social media variable in this study consisted solely of Facebook usage; the findings may have been different had other prominent social media platforms been represented.

Implications for Future Research

Future research efforts should continue to explore the mental health implications of the study’s variables. First, it would be useful to confirm the findings with a more gender-representative sample. The model should also be explored with a longitudinal sample to determine mental health trajectories through various transitions common during the college experience. It would also be useful to explore potential mediating effects among the variables in the model, which could provide further empirical support for the theoretical sequencing of the variable sets. Other research efforts could further explore the therapeutic applications of social media. Such efforts could aid understanding of the evolving needs of college-aged populations.


The college years constitute considerable mental health risks that seem particularly pronounced for current generations of traditional-aged college students. The present findings suggest that traditional models of college student mental health can be aided by also incorporating generation-specific factors, including emerging adulthood identification and social media usage. Such generation-specific factors seem to predict unique variance in college student mental health characteristics, namely PWB and life satisfaction. The findings underscore the importance that counselors consider contemporary models, including emerging adulthood theory, when conceptualizing and treating traditional-aged college student clients.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.




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Joel A. Lane, PhD, NCC, LPC, is an associate professor and department chair at Portland State University. Correspondence may be addressed to Joel Lane, 250G Fourth Avenue Building, 1900 SW 4th Ave., Portland, OR 97201, lanejoel@pdx.edu.

Serving Students in Foster Care: Implications and Interventions for School Counselors

Hannah Brinser, Addy Wissel


Students in foster care frequently experience barriers that influence their personal, social, and academic success. These challenges may include trauma, abuse, neglect, and loss—all of which influence a student’s ability to be successful in school. Combined with these experiences, students in foster care lack the same access to resources and support as their peers. To this end, school counselors have the opportunity to utilize their unique position within the school community to effectively serve and address the complex needs of students in foster care. This paper addresses the current research, presenting problems, implications, and interventions school counselors can utilize when working with this population.

Keywords: students, foster care, school counseling, support, interventions


In 2017, there were a total of 442,995 children and youth in the foster care system (U.S. Department of Health and Human Services, 2018). Given the number of these students in schools and communities, school counselors have the opportunity to utilize their position within the school system to identify, respond to, and advocate for the needs of students in foster care to ensure equity and access in all areas. Although all students need positive relationships and stability to be successful, students in foster care often lack the same access to support, resources, and opportunities as their peers (McKellar & Cowen, 2011; Palmieri & La Salle, 2017). These barriers and challenges contribute to gaps in achievement, relationships, and skills for these students (Palmieri & La Salle, 2017). Compared to their peers, students in foster care are more likely to be absent from school, repeat a grade, and change schools (Cutuli et al., 2013; Palmieri & La Salle, 2017; Unrau et al., 2012), which ultimately impacts their ability to establish and maintain relationships. Additionally, students in foster care are twice as likely to receive out-of-school suspensions, over three times as likely to receive special education services, and over 20% less likely to graduate from high school (National Working Group for Foster Care and Education [NWGFCE], 2018).

When it comes to higher education, students in foster care are less likely to enroll in college preparatory classes, attend college, and obtain a 4-year degree when compared to their peers (Kirk et al., 2013; Unrau et al., 2012). Research suggests that as little as 3%–10.8% of youth previously in foster care attain a 4-year degree, compared to the national college completion rate of 32.5% (NWGFCE, 2018). However, it is important for school counselors to realize that between 70%–84% of students in foster care desire going to college (Courtney et al., 2010; NWGFCE, 2018). Although students in foster care feel motivated to attend and complete college, academic achievement can easily become another barrier. On average, students in foster care receive both lower ACT scores and high school GPAs and perform lower on standardized tests compared to their peers—all of which influence one’s admission to college (O’Malley et al., 2015; Unrau et al., 2012).

Unfortunately, it is also common for students in foster care to experience other challenges that influence their success in school, such as trauma. Trauma can include abuse; neglect; and the loss of family members, friends, and communities (Scherr, 2014). Without adequate support, trauma can impact a student’s executive functioning and memory, ultimately affecting their ability to learn (Avery & Freundlich, 2009). Additionally, separation from family members, disrupted relationships, and frequent transitions lead to an increased risk for difficulties in expressing and regulating emotions, tolerating ambiguity, and problem-solving (O’Malley et al., 2015; Unrau et al., 2012). These interrelated and complex factors contribute to the achievement gap experienced by students in foster care as evidenced by lower academic achievement and less engagement in school (Pecora et al., 2006; Unrau et al., 2012).

Importance of Serving This Population


When considering interventions to support students in foster care, it is important to explore what they believe will be helpful for their growth and success. It is likely that the majority of students in foster care already feel a lack of control over what occurs in their lives (Scherr, 2014). Therefore, this is an opportunity to encourage student involvement while increasing student self-efficacy. Clemens et al. (2017) found that students in foster care emphasize the importance of having opportunities to connect with others in similar situations, learning practical skills, and implementing different strategies to better their lives. To provide a sense of normalcy and belonging, school counselors can advocate for interventions that promote connectedness and engagement with other students (Unrau et al., 2012).

Removing barriers, improving access to services, maintaining enrollment, improving attendance, and facilitating academic progress is critical in promoting success for students in foster care (Gilligan, 2007). Therefore, school counselors should be aware of the barriers related to access that exist for students in foster care and should be intentional in taking steps to remove any inequities. Working proactively and using a strengths-based approach that acknowledges the skills, strengths, and resiliency of students are ways in which school counselors can effectively meet the needs of students in foster care (Gilligan, 2007; Scherr, 2014). To illustrate, a strengths-based approach can be utilized with students who have anxious attachment patterns by acknowledging their ability to care for others, rather than focusing on the negative aspects of their attachment behaviors (e.g., being too “needy”). Although it can be easy to focus on the behaviors and disruptions that occur, school counselors have the opportunity to instead focus on these students’ accomplishments, strengths, and dreams. Ultimately, it is evident that students in foster care face many challenges that influence their ability to be successful. In an effort to address this need, the following section outlines interventions for school counselors to use when working with students in foster care.


School Climate
Positive school relationships are an essential part of school climate and can serve as a protective factor for students experiencing adversity (Furlong et al., 2011; O’Malley et al., 2015). Therefore, focusing on school climate may be an effective approach in supporting students in foster care, as positive school relationships can also help close achievement gaps between these students and their peers (Clemens et al., 2017). For example, positive school climate decreases rates of disruptive behaviors, truancy, fights, and suspensions at school (Hopson & Lee, 2011). In addition, Voight et al. (2013) found that students’ positive school climate perceptions also contributed to academic achievement as indicated by state standardized test scores. School counselors can enhance school climate by allowing student voices, utilizing empowerment strategies, implementing evidence-based programs, providing adult mentoring (O’Malley et al., 2015), and working to create a positive peer culture (Bergin & Bergin, 2009).

School Culture
It is particularly important to pay attention to school culture, as these shared norms, beliefs, and behaviors affect perceptions of school climate (MacNeil et al., 2009). To create a positive school culture, Ziomek-Daigle et al. (2016) recommended that school counselors implement interventions using a multi-tiered system of supports. For example, providing classroom lessons on topics such as kindness, empathy, and acceptance are Tier 1 interventions that work to cultivate a positive school culture (Bergin & Bergin, 2009; Ziomek-Daigle et al., 2016). Additionally, school culture can be influenced by creating shared values and expectations for students throughout the school community (MacNeil et al., 2009). For example, school counselors can utilize empowerment strategies when teaching students in foster care to advocate for themselves and find autonomy in meeting their needs. The school counselor might say, “Last week, you worked so hard at learning to use ‘I statements’ when expressing your needs and feelings to others! In class, I even saw that you raised your hand to ask for a break when you started to get overwhelmed in math. How might you use similar skills to advocate for yourself when you get frustrated in social studies?” In this way, the school counselor is improving school culture by creating a shared expectation among students, teachers, and staff.

Educational Experiences
Moreover, school counselors can enhance school climate by facilitating enriching educational experiences that contribute to academic success (Gilligan, 2007). To ensure that students in the foster care system receive the same educational experiences as their peers, school counselors can screen, monitor, plan, communicate, and collaborate with other stakeholders (e.g., teachers, administration, staff, and foster families) to ensure equity and access for students in foster care (Palmieri & La Salle, 2017). Educating stakeholders about working with students in foster care can encourage inclusive assignments, promote an understanding of potential responses and reactions from students, and decrease negative behavioral perceptions (McKellar & Cowen, 2011). Additionally, including students in decisions about their education, where they attend school, and the support they receive can increase their self-efficacy, goal development, and self-advocacy skills (Palmieri & La Salle, 2017). This intentionality can also help them feel welcome, respected, and important—all of which increase their school connection.

Collaborating With Stakeholders
     School counselors should plan to accommodate and work with students who may enter school in the middle of the year, as 34% of students in foster care experience five or more school changes by the time they reach the age of 18 (NWGFCE, 2018). When these students arrive at school, it is important that school counselors welcome them, explain classroom and school procedures, show them around the school, and facilitate connections with other students (Palmieri & La Salle, 2017). From the beginning, school counselors can prioritize involving the foster family by calling to welcome them, answering any questions they have, providing them with helpful information (e.g., teacher contact information), and following up with them after a few weeks. For example, packets can be sent home with students so foster families have access to any relevant documents or previous newsletters containing helpful information (McKellar & Cowen, 2011). Additionally, it may be beneficial for school counselors to invite the foster family to meet with them in person to create a stronger foster family and school partnership. Furthermore, incomplete student records can have a significant effect on academic services for students in foster care. Therefore, school counselors should work diligently with other school districts to retrieve and maintain these records (McKellar & Cowen, 2011).

Along with planning, school counselors can provide all stakeholders with evidence-based information to effectively serve and address the needs of students in foster care (Kerr & Cossar, 2014). With this purpose in mind, school counselors can provide training to stakeholders on topics such as reflective listening, creating secure attachments, recognizing and responding to feelings and behaviors, and setting limits and boundaries (Kerr & Cossar, 2014). Informed stakeholders can more effectively support and respond to the unique needs of students in foster care, and in turn, students may be more successful in managing their emotions and behaviors (Palmieri & La Salle, 2017). This awareness can also strengthen relationships that promote school success (Kerr & Cossar, 2014). Additionally, school counselors can be proactive in collaborating with stakeholders to create structured and supportive classroom environments where students in foster care feel safe while learning. For example, working with teachers to modify assignments that have the potential to be triggering (e.g., family-based assignments) is essential in promoting student–teacher relationships and academic achievement (C. Mitchell, 2010; Palmieri & La Salle, 2017).

     Students in foster care often experience triggers at school, whether it is from an assignment (e.g., family-based assignments), a topic discussed in class, or a community event that seems to be exclusively for biological parents (West et al., 2014). When these experiences occur, students in foster care do not always have the ability to self-regulate and utilize healthy coping skills (West et al., 2014). For this reason, it is essential to not only advocate for inclusive assignments and events but to also help students effectively manage their triggers so they can be academically and relationally successful. Additionally, it may be helpful to provide stakeholders with information about why certain activities lack inclusivity for students in foster care and offer possible alternatives or modifications for these experiences. To illustrate, events such as “Muffins with Moms” and “Donuts with Dads” can be altered for inclusivity by expanding the population to include anyone in the student’s support system (e.g., “Floats with Friends” or “Popcorn with Important People”).

Additionally, an assignment about creating a family tree could be modified for inclusivity by focusing on the diversity of family structures. C. Mitchell (2010) offers the alternative of creating “The Rooted Family Tree,” in which the roots represent one’s birth family, the student as the trunk, and the foster or adoptive family filling in the branches. Similarly, “The Family Houses Diagram” utilizes houses instead of trees to allow for multiple places of living and the option to form a connection between birth, foster, or other family types (C. Mitchell, 2010). Another common assignment given in schools is to bring a baby picture to share with the class. This lacks inclusivity for students in foster care, as they might not have these pictures or there may be difficult memories attached to them. Additionally, this puts the student in the painful position of having to explain why they do not have these pictures (C. Mitchell, 2010). As a result, C. Mitchell (2010) recommends framing the assignment as a choice: Bring a picture of yourself as a baby or at a younger age, on a vacation or holiday, or engaging in any activity that you enjoy.

Knowing how to cultivate secure attachments with students in foster care is especially relevant for stakeholders, as positive student–adult relationships can influence other relationships in the student’s life by altering their internal working model (Bergin & Bergin, 2009; Sabol & Pianta, 2012). Although it can be difficult to create and maintain secure relationships with students who experience insecure attachment (Bergin & Bergin, 2009), stakeholders have the opportunity to fill in attachment gaps that may exist for students in foster care. Secure attachment is related to higher grades and standardized test scores, increased emotion regulation, and higher self-efficacy (Bergin & Bergin, 2009; Golding et al., 2013). Moreover, students with insecure attachment tend to show less curiosity (Granot & Mayseless, 2001), have poorer quality friendships, and exhibit behavior problems (Bergin & Bergin, 2009; Golding et al., 2013).

Importantly, attachment to teachers, rather than just biological parents, is linked to school success (O’Connor & McCartney, 2007; Sabol & Pianta, 2012). When students have healthy relationships with their teachers and perceive them as supportive, they show greater interest and engagement in school, which leads to improvements in academic achievement (Bergin & Bergin, 2009; Golding et al., 2013). Additionally, students who experience insecure attachment crave positive, warm, and trusting relationships but often lack the skills to create them. For this reason, stakeholders can help nurture secure relationships by being genuine, maintaining high expectations, and providing as much choice and autonomy as possible (Bergin & Bergin, 2009). Furthermore, noticing when these students are not at school, or when they return after an absence, can help them know they are valued and cared for.

To advocate, school counselors can help stakeholders understand why students with insecure attachment are behaving and reacting in certain ways, while also helping staff to respond in ways that disconfirm students’ insecure working models (Bergin & Bergin, 2009). In this way, staff can show that students’ particular beliefs about relationships with others may not always be true. To illustrate, not asking for help in the classroom, ignoring the teacher, or denying the need for assistance could be a manifestation of an insecure avoidant attachment style (Golding et al., 2013). This student does not want to become close or show vulnerability, as they fear that the teacher will reject or separate from them (e.g., their internal working model). For these students, it can be easier to not ask for help or engage in classroom projects at all than risk the hurt of rejection (Golding et al., 2013). A teacher who misunderstands this might believe they are unable to adequately support the student. As a result, they may stop trying to help, which confirms the student’s internal working model of fear and rejection. Instead, the teacher can disconfirm this student’s internal working model by providing reassurance of their consistency and availability (Golding et al., 2013). For example, the teacher conveying that they want to help, while also asking how they can help, offers healthy choice and autonomy. Encouraging small changes in how stakeholders respond to students in foster care provides a space for positive and secure relationships to develop.

Skill Development and Addressing Unique Experiences
Behavior Management, Emotion Regulation, and Social Skills
     Difficulties in behavior management, emotion regulation, and social skills are common among students in the foster care system, as they lack control over many events that occur in their lives (Octoman et al., 2014; Scherr, 2014). These students’ unique and complex experiences can impact their ability to appropriately manage their emotions, behaviors, and interactions with others. Unfortunately, these extreme emotions and behaviors often result in several different placements, the loss of relationships, and the loss of school and community connections (Octoman et al., 2014).

Given this information, school counselors can contribute to student success by collaborating with stakeholders to communicate appropriate behavior, identify boundaries, and explicitly state expectations. Providing behavioral support, management, and individual attention can help students engage in positive behaviors that facilitate their success at school and in the classroom (Palmieri & La Salle, 2017). Additionally, working with students to identify and manage emotions decreases externalizing behaviors, reduces stress levels, and improves relationships. Likewise, providing education about control, acceptance, coping skills, and distress tolerance are applicable emotion regulation interventions to utilize with students in foster care (Benzies & Mychasiuk, 2009). Groups and interventions on topics such as social skills, problem-solving, making and keeping friends, and appropriate behaviors can help students develop healthy interpersonal relationships (Scherr, 2014; Zins & Elias, 2007).

Grief and Loss
Additionally, it is crucial that school counselors intentionally address the unique and complex experiences of students in foster care. For example, these students often experience non-death losses that go unacknowledged, including the loss of parents, siblings, friends, and communities (M. B. Mitchell, 2018). These losses may involve a lack of clarity and create confusion about a loved one’s physical or psychological presence, commonly referred to as ambiguous loss (Boss, 1999; Lee & Whiting, 2007). To illustrate, being separated from one’s family and placed into foster care can generate grief and loss reactions, including confusion, isolation, distress, uncertainty, helplessness, denial, extreme behaviors, and guilt (Lee & Whiting, 2007; M. B. Mitchell & Kuczynski, 2010). Disenfranchised grief occurs when others disregard and do not acknowledge a loss (Doka, 1989; M. B. Mitchell, 2018). Unfortunately, it is common for the child welfare system and society to ignore experiences of grief and loss in foster care (M. B. Mitchell, 2018; M. B. Mitchell & Kuczynski, 2010).

In an effort to address this, school counselors can begin by identifying, acknowledging, and validating losses that are not caused by death but produce many similar grief responses (M. B. Mitchell, 2016, 2018). Additionally, school counselors can educate stakeholders about ambiguous loss and disenfranchised grief, as it is important for the entire school community to have an understanding about manifestations of grief and loss when working with these students (e.g., internalizing and externalizing). In general, school counselors can advocate for students in foster care by validating their experiences, equipping them with education and resources, helping others understand why their experiences embody grief and loss, and acknowledging the inherent confusion involved in their unique situations (Lee & Whiting, 2007).

Accessing School and Community Resources
School Engagement
     Students involved in their school community through extracurricular activities, leadership, and positions of responsibility often experience more motivation and engagement in learning (Gilligan, 2007). Additionally, such engagement is beneficial in creating a sense of normalcy, belonging, and community with other students. Unfortunately, these opportunities can seem limited to students in the foster care system because of cost, timing, and transportation barriers (Palmieri & La Salle, 2017). Therefore, it is critical that school counselors collaborate, advocate, and act to remove these barriers, as engagement in the school community can result in academic, social, and behavioral improvements (Scherr, 2014). School counselors can facilitate this involvement and engagement in the school community by collaborating with other stakeholders to provide opportunities. For example, encouraging and assisting students in foster care to navigate and obtain leadership positions (e.g., student government) will not only improve their engagement in school, but also increase their self-efficacy and sense of belonging within the school community. Additionally, school counselors can collaborate with other professionals (e.g., social workers, school psychologists, and school nurses) to identify and address different areas of support, resources, and opportunities for these students.

Group Counseling
With a national student–school counselor ratio of 455:1 (American School Counselor Association, 2019), group counseling is a promising approach to help school counselors meet the complex needs of students who are in foster care. Additionally, this is an effective way to encourage involvement and connectedness with students who have similar backgrounds, while providing these students with the skills that they need to be successful (Palmieri & La Salle, 2017). Involvement in group counseling can help create a sense of normalcy, belonging, and community with other students (Alvord & Grados, 2005) and can also result in academic, social, and behavioral improvements (Scherr, 2014).

Hambrick et al. (2016) found that children in foster care experienced improvements in behavior, academics, quality of life, attachment, placement stability, and emotion regulation following their participation in group-based interventions. Although participating in a small group with other students in the foster care system may provide the opportunity to feel understood and less alone, students may also benefit from engaging in group activities with typical peers. For example, students in foster care might participate in a “lunch bunch” group where they eat in community with the school counselor and other like-age peers. In these groups, students can play, learn from watching the interactions of peers, and develop the skills necessary for initiating and maintaining positive peer relationships.

Utilizing a reality therapy approach for group counseling seems particularly beneficial, as it addresses choice, control, and healthy ways of getting one’s needs met—all common issues students in foster care may struggle with (Benzies & Mychasiuk, 2009; Cameron, 2013; Kress et al., 2019). These components are essential in empowering students to choose how they respond to and face the challenges in their lives (Benzies & Mychasiuk, 2009). In this approach, school counselors can assume the roles of teacher, advocate, and encourager by educating about responsibility, choices, and the importance of meaningful relationships (Kress et al., 2019). Utilizing the WDEP system (i.e., wants, doing, evaluation, and planning) to explore questions, including “What do you want?”, “What are you doing?”, and “Is it working?”, helps students assess if their current behaviors are getting them what they desire, and if they are not, how they can change in healthy ways (Wubbolding, 2011).

Because behavior is intentional, it is beneficial to look at each student’s behavior as an attempt to satisfy their needs (Glasser, 1984, 2000). Additionally, focusing on the here and now is helpful in guiding and educating students about effective and appropriate ways to get their needs met by others (Glasser, 1992, 2000). As many students in foster care have not always had their needs met in the past, they must learn to have their needs met in healthy and effective ways (Octoman et al., 2014). For example, a student who is grabbing and touching other students might be trying to get their need of love and belonging met. In this situation, it would be a helpful learning experience to guide this student to meet this need in a different way, such as asking the peer permission for a hug or setting aside time to spend with them later (Octoman et al., 2014).

When using this approach, school counselors can reframe behavior to emphasize student strengths, identify and celebrate students’ acceptance of choice and responsibility, create anticipation for change, and communicate hope about success (Kress et al., 2019). School counselors can also prioritize rapport building; creating safety through rules, goals, and expectations; and helping students realize that they are not alone in their experiences (Alvord & Grados, 2005; Gladding, 2016; Kress et al., 2019). Other small groups that address issues such as social skills, making and keeping friends, and college and career exploration may also be helpful for students in foster care.

Mentorship Programs
Students in the foster care system experience many transitions and losses, which can result in disruptions to the adult and peer relationships that support educational success. In this way, mentorship programs work to reduce risk and provide protective support to students in foster care (Scherr, 2014). These students value having a mentor who provides support and encouragement on topics related to academics, college, and life (Clemens et al., 2017; Dworsky & Pérez , 2010) and benefit from having a consistent, trustworthy, and non-familial adult in their lives (Benzies & Mychasiuk, 2009). Mentorship programs contribute to fewer behavior referrals, less school mobility, and improved graduation rates (Salazar et al., 2016). Additionally, the accountability of mentorship can motivate students to improve their attendance, achievement, and engagement in school. Given this information, facilitating connectedness and mentorship for these students is crucial in providing them with the support, consistency, and encouragement they need to accomplish their goals.

The Check and Connect Model is evidence-based and targets students who show warning signs of disengaging from school such as poor attendance, behavioral issues, and low grades (Tilbury et al., 2014), all of which are particularly relevant for students in foster care. Potential mentors can be natural (e.g., someone already present and supportive in the student’s life) or someone from the community interested in volunteering (Salazar et al., 2016). Utilizing natural mentors, if available, is beneficial in acknowledging the natural supports that already exist in students’ lives. For example, if a student already has a trusting relationship with a staff member, it is important to utilize this connection to maintain stability. However, if a student is unable to identify any natural mentors, working with volunteers in the community is also an excellent option. Both are impactful in different ways, and the quality of the connection is what is really crucial (Salazar et al., 2016).

It is essential that mentors are consistent, empathetic, authentic, and committed to supporting students in foster care. Mentors not only serve as a relational connection for these students but also help youth expand their social support networks, set goals, explore postsecondary options, and increase involvement in the school community (Salazar et al., 2016). School counselors can work with mentors to monitor student performance variables, such as absences, behavioral referrals, and grades, while helping students solve problems, identify skills, and reach their goals (University of Minnesota, 2019). Mentorship programs should be flexible and tailored to the needs of each student and their mentor, as some pairs might benefit from more or less time to connect (Salazar et al., 2016). Ultimately, these programs can be helpful in providing students in foster care with the connection and support they need to be successful, while also contributing to the development of other secure relationships in their lives (Palmieri & La Salle, 2017).

Community Partnerships
     For students in foster care, it is essential that support extends beyond the school community. To do this, school counselors can establish relationships and collaborate with the student, foster family, school, and foster care system (Palmieri & La Salle, 2017). These home–school partnerships are critical in meeting the needs of students in foster care. Additionally, foster families feel more supported when they are involved and their input is valued (Palmieri & La Salle, 2017). Utilizing and forming plans around academic and behavioral expectations, attendance, flexibility with requirements, and communication with stakeholders can be helpful in promoting success (McKellar & Cowen, 2011). Furthermore, tangible and emotional support can act as protective factors and meet the needs of students through the provision of goods and services (Piel et al., 2017). For example, school counselors can create or utilize community-based food and nutrition programs to ensure that basic needs are being met.

Mental Health Services
Equally important, students in foster care often experience difficulties that affect their mental health. Evidence-based treatments such as trauma-focused cognitive behavior therapy (TF-CBT), behavior therapy, cognitive behavior therapy (CBT), and parent–child interaction therapy can be adapted for the school setting (Landsverk et al., 2009). These models of counseling are helpful in addressing symptoms, while also promoting healthy behavior and functioning. Combined with this, school counselors can also provide outpatient information to foster families and case workers about local resources and services available to students in foster care. In these cases, it is helpful to collaborate with the designated outpatient counselor to provide the most effective support and generalize learned skills across settings (Landsverk et al., 2009).


Students in foster care experience a number of barriers and challenges that influence their success in school, both academically and socially, as well as in adulthood. In addition, students in foster care lack the same access to resources and support as their peers, which contributes to gaps in academic achievement, relational success, and overall well-being. By enhancing school climate, planning, providing training to stakeholders, and promoting positive educational experiences, students in foster care can receive the foundational support they need to begin learning. Additionally, by utilizing group counseling, implementing mentorship programs, targeting specific behavior, addressing experiences of grief and loss, and accessing community resources, students in foster care can gain the skills they need to be successful in all areas. Despite the many challenges students in foster care face, school counselors have the opportunity to utilize their unique position in their schools and communities to advocate for these students, reach them through evidence-based interventions, remove barriers to learning, and ultimately equip them with the tools and skills they need to experience greater success.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Hannah Brinser is a master’s candidate at Gonzaga University. Addy Wissel, PhD, is an associate professor and program director at Gonzaga University. Correspondence may be addressed to Hannah Brinser, 502 E. Boone Ave., Spokane, WA 99258, hannahbrinser@gmail.com.

Clinical Work With Clients Who Self-Injure: A Descriptive Study

Amanda Giordano, Lindsay A. Lundeen, Chelsea M. Scoffone, Erin P. Kilpatrick, Frank B. Gorritz


Nonsuicidal self-injury (NSSI) is a common clinical concern. We surveyed a national sample of 94 licensed clinicians to better understand their work with clients who self-injure. Our data revealed that over the past year, 95.7% (n = 90) of the sample reported working with at least one client who self-injured. Thirty-six clinicians (38%) reported that most or all of their clients who self-injured were adolescents, 61 (64.9%) reported that most or all clients who self-injured were female, and 43 (45.7%) reported that most or all clients who self-injured engaged in cutting as the primary NSSI method. About 35% (n = 33) of the clinicians in our sample indicated they have never asked clients who self-injured about their online activity related to NSSI. The majority of our participants (n = 78; 83%) supported the notion that NSSI could be an addictive behavior for some clients and less than half (n = 42; 44.7%) received NSSI training in their graduate coursework. 

Keywords: nonsuicidal self-injury, NSSI, licensed clinicians, training, behavioral addiction  


Nonsuicidal self-injury (NSSI) is a complex phenomenon. Favazza (1998) defined NSSI as “the deliberate, direct destruction or alteration of body tissue without conscious suicidal intent” (p. 260). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) noted that NSSI is intentional and self-inflicted body damage that is not socially sanctioned (e.g., piercings or tattoos) and lacks suicidal intent. The fact that NSSI is intentional and direct distinguishes it from unplanned or indirect forms of self-harm such as disordered eating or substance abuse (Favazza, 1998; Walsh, 2012). Furthermore, although a relationship exists, NSSI is distinct from suicide attempts in that it is a means of seeking relief and coping, thereby sustaining rather than ending one’s life (Walsh, 2012; Wester & Trepal, 2017). NSSI has been conceptualized as a behavioral addiction (Buser & Buser, 2013) given that some clients demonstrate a loss of control over NSSI, continued engagement despite negative consequences, craving to engage in NSSI, and compulsivity, which are hallmarks of addiction. Also, researchers have found evidence for NSSI contagion, in which the behavior is imitated by others in a specific community (Walsh, 2012; Walsh & Rosen, 1985). Given these complexities, it is imperative that clinicians are adequately trained to assess and treat NSSI.

In light of previously published prevalence rates, it is likely that most clinicians will work with clients who self-injure at some point in their careers. Indeed, 21%–80% of inpatient clients and 22%–40% of outpatient clients have reported engagement in self-injurious behavior (Wester & Trepal, 2017). Moreover, in a national sample of 74 clinical practitioners, 60 (81%) reported working with clients who self-injured (Trepal & Wester, 2007), and among 443 school counselors, 357 (81%) reported working with at least one student engaged in self-injury (Roberts-Dobie & Donatelle, 2007). Much has changed, however, in the social landscape related to self-injury, including the popularity of sharing NSSI images online; television shows, movies, and songs depicting NSSI; and celebrities disclosing NSSI behavior. Thus, we sought to investigate licensed clinicians’ experiences working with clients who self-injure to provide updated information and better inform the profession of counseling.

Terminology and Prevalence of NSSI

NSSI is not a new abnormal behavior. Indeed, it was documented in the gospel account of Mark written between A.D. 55 and 65, in which the author described a man cutting himself with stones (Mark 5:5; NIV Life Application Study Bible, 1984). Self-injurious behavior has been labeled self-mutilation, self-harm, deliberate self-harm, parasuicide, cutting, and non-suicidal self-directed violence (Wester & Trepal, 2017). In this paper, we use the term nonsuicidal self-injury (NSSI) as it is currently listed as the proposed diagnosis in the DSM-5 (Section III, Conditions for Further Study; APA, 2013).

Current prevalence rates indicate that NSSI affects a substantial portion of the population, particularly female adolescents (Nock, 2009; Wester & Trepal, 2017). For example, in a study of 665 adolescents, researchers determined that 8% engaged in NSSI at some point in their lives, which included 9% of the females in the sample and 6.7% of the males (Barrocas et al., 2012). Furthermore, Doyle and colleagues (2017) surveyed adolescents in Ireland and found that 12% had engaged in NSSI, the majority (72.8%) of which were female. Moreover, the examination of data from emergency room visits among youth in the United States (10–24 years of age) indicated a rise in non-fatal self-inflicted injury among females (with and without suicidal intent) from 2001 to 2015 (Mercado et al., 2017). Specifically, self-inflicted injuries with a sharp object rose from 261 incidents in 2001 to 1,021 incidents in 2015 (Mercado et al., 2017). Along with adolescent populations, NSSI is a growing concern among young adults. Wester et al. (2018) examined NSSI among three cohorts of freshman college students and found that lifetime NSSI increased from 16% in the 2008 cohort to 45% in the 2015 cohort. Additionally, current NSSI increased from 2.6% in the 2008 cohort to 19.4% in the 2015 cohort (Wester et al., 2018).

Motives for NSSI

The function of NSSI can be challenging to comprehend among those who do not engage in the behavior. Criterion B in the proposed criteria for NSSI Disorder in the DSM-5 (APA, 2013) highlighted three potential functions: (a) to relieve negative feelings and cognitions, (b) to address relational difficulties, and (c) to stimulate positive feelings. Indeed, emotion regulation is a primary motivation for NSSI (Nock, 2009). Among 108 adolescents in inpatient treatment who engaged in self-injurious thoughts or behaviors, Nock and Prinstein (2004) found 52.9% engaged in NSSI to relieve negative emotions, 34.1% engaged to feel something, and 30.6% engaged as a form of self-punishment. Doyle et al. (2017) found 79% of adolescents who engaged in NSSI did so to find relief from negative emotions or cognitions, 38% engaged to punish themselves, and 35% sought to communicate the extent of their distress. In light of the many means of emotion regulation that exist, Nock (2009) identified three reasons why some individuals choose NSSI: (a) as a result of social learning from the media, friends, and family; (b) as a form of punishment via self-directed abuse; and (c) as a means of social signaling, or communicating with others (particularly when other forms of communication were ineffective). Engaging in NSSI may be a more accessible, affordable, and easy-to-hide method of emotion regulation compared to other strategies such as substance abuse (Nock, 2009).

NSSI Social Contagion

One important consideration related to NSSI is social contagion, or the engagement in a behavior by at least two people in a group within 24 hours (Jarvi et al., 2013; Walsh, 2012; Walsh & Rosen, 1985; Wester & Trepal, 2017). Individuals can become exposed to NSSI through peers, family members, media, and song lyrics, which contribute to social learning (Jarvi et al., 2013; Nock, 2009) and potentially sensationalize the behavior (Walsh, 2012). In a review of the literature, researchers found 16 studies supporting the association between social contagion and NSSI (Jarvi et al., 2013). In a seminal work, Walsh and Rosen (1985) studied the behavior of 25 adolescents in treatment for various mental health diagnoses for one year. The researchers analyzed the frequency and timing of particular behaviors, including NSSI, and found significant clustering of self-injurious incidents, supporting contagion for NSSI among the group. Furthermore, researchers have found that a small portion of those who engage in NSSI do so to influence others (e.g., get the attention of a particular person, manipulate others, or elicit care; Doyle et al., 2017; Nock, 2008).

In light of the ubiquitous nature of the internet, NSSI social contagion may occur among online groups, as well as those that exist offline. Walsh (2012) noted that factors contributing to social contagion offline can also occur online within the context of social networking sites, message boards, chat rooms, and YouTube. Researchers have confirmed the prevalence of NSSI images and videos online. Lewis and colleagues (2011) investigated NSSI videos on YouTube and found that the top 100 NSSI videos were viewed over 2 million times. Miguel et al. (2017) found 770 NSSI-related images on three social media platforms in a 6-month period using one search term (#cutting). The researchers classified 59.5% of the images as graphic in nature (Miguel et al., 2017). Although there are potential benefits of online communication about NSSI, such as encouraging help-seeking and support, online NSSI-related images and videos pose risks as well. Lewis et al. (2012) noted that online mediums may provide reinforcement for NSSI, provide tips and strategies (such as first aid considerations), and trigger urges among users to engage in NSSI.

NSSI as a Behavioral Addiction

Given its seemingly compulsive nature, some authors have proposed the conceptualization of NSSI as a behavioral addiction (Buser & Buser, 2013; Davis & Lewis, 2019). Indeed, Buser and Buser (2013) posited that for some individuals, NSSI reflects the commonly used criteria for addiction, including compulsivity, loss of control, continuation despite negative consequences, relief from negative emotions, and tolerance. Specifically, tolerance to NSSI can develop as a result of frequent activation of the endogenous opioid system, to which the individual becomes less sensitive (Buser & Buser, 2013; Walsh, 2012). Tolerance among those who self-injure may manifest as increased frequency of NSSI, increased severity of skin tissue damage, or the use of additional NSSI methods (Wester & Trepal, 2017). In the content analysis of 500 posts on NSSI online message boards, Davis and Lewis (2019) determined six themes that underscored the addictive nature of NSSI: urge/obsession, relapse, can’t/don’t want to stop, coping mechanism, hiding shame, and getting worse/not enough. These themes indicate that some individuals who engage in NSSI experience cravings, a loss of control, urges, and relapse—all common features of addictive behaviors (American Society of Addiction Medicine, 2019). Given the growing acceptance of behavioral addictions, as evidenced by recent changes and additions to both the DSM-5 (APA, 2013) and the International Classification of Diseases (ICD-11; World Health Organization, 2018), it is important to assess whether clinicians working with clients who self-injure conceptualize the behavior as addictive.

Purpose of the Study

     Although some researchers have investigated the experience of clinicians addressing clients who self-injure (Roberts-Dobie & Donatelle, 2007; Trepal & Wester, 2007), the growing prevalence of NSSI (Mercado et al., 2017; Wester et al., 2018) warrants updated information. Therefore, we designed the current study to explore licensed clinicians’ experiences with clients who engage in self-injurious behaviors. Specifically, we sought to examine the frequency of addressing NSSI in clinical work, characteristics of clients who self-injure, NSSI assessment practices, the role of the internet in NSSI, clinicians’ beliefs pertaining to NSSI, and clinical training and competence.



Our sample consisted of 94 licensed clinicians in the United States. Participants ranged in age from 26 to 70 years old with a mean age of 45 (SD = 11.06). Eighty (85.1%) participants identified as White, six (6.4%) as Black/African American, three (3.2%) as biracial/multiracial, three (3.2%) as other, and two (2.1%) as Latino(a)/Hispanic. With regard to gender, 79 (84%) participants identified as female, 13 (13.8%) as male, one (1.1%) as transgender, and one (1.1%) as other. Of the 94 participants, 82 (87.2%) identified as heterosexual, five (5.3%) as bisexual, three (3.2%) as queer, two (2.1%) as lesbian, and one (1.1%) each as gay and other.

In relation to professional background, the clinicians represented varying degree levels and educational fields of study. Most of the participants’ highest degree was a master’s (n = 86; 91.5%), while seven (7.4%) earned a doctoral degree, and one (1.1%) participant earned a specialist degree. Fifty-six (59.6%) of the participants reported that their highest degree was from a CACREP-accredited program, while 26 (27.7%) of the participants came from a non–CACREP-accredited program, and 12 (12.8%) did not answer the question. Some diversity existed among participants’ programs of study and licensure: 51 (54.3%) participants studied professional counseling or counselor education, 27 (28.7%) studied counseling psychology, seven (7.4%) studied clinical psychology, six (6.4%) studied other areas not listed, and three (3.2%) studied rehabilitation counseling. In terms of licensure, 47 (50%) participants were licensed professional counselors (LPCs), 19 (20.2%) were licensed mental health counselors (LMHCs), 15 (16%) were licensed professional clinical counselors (LPCCs), 11 (11.7%) held licensures not listed in our questionnaire, 11 (11.7%) were licensed clinical professional counselors (LCPCs), seven (7.4%) were licensed clinical mental health counselors (LCMHCs), four (4.3%) were licensed professional counselors of mental health (LPCMHs), three (3.2%) were licensed marriage and family therapists (LMFTs), and one (1.1%) was a licensed chemical dependency counselor (LCDC).

The participants had varying years of clinical experience. Eighteen (19.1%) participants had been counseling clients for 1–5 years, 43 (45.7%) for 6–10 years, 17 (18.1%) for 11–15 years, six (6.4%) for 16–20 years, three (3.2%) for 21–25 years, five (5.3%) for 26–30 years, and two (2.1%) for more than 30 years. All participants stated they were currently seeing clients. We asked participants to describe their typical client base by selecting all applicable responses: 84 (89.4%) of the participants counseled adults, 37 (39.4%) counseled adolescents, 37 (39.4%) counseled college students, 27 (28.7%) counseled couples, 19 (20.2%) counseled children, and 12 (12.8%) counseled families.


Similar to the approach employed by Trepal and Wester (2007), our questionnaire consisted of two sections: participants’ demographics and clinical experiences with NSSI. In the demographics section, we assessed participants’ age, race, ethnicity, gender, sexual orientation, education, clinical license, and typical client base. Next, to better understand clinical work with clients who self-injure, we compiled a series of descriptive, Likert-type assessment items. Specifically, the questionnaire items explored how often clinicians addressed issues of NSSI in counseling, characteristics of clients who self-injured, methods of assessing NSSI, clients’ internet and social networking activity pertaining to self-injury, the extent to which clinicians conceptualized NSSI as an addiction and whether NSSI should be a formal diagnosis included in the DSM proper (rather than as an appendix), extent of clinical training pertaining to NSSI, and perceived clinical competence when working with issues of NSSI among clients. In sum, the questionnaire contained 22 items related to clinical work with NSSI.


We acquired our national sample of licensed clinical participants using the clinician database on the Psychology Today website. Specifically, we conducted a search of clinicians with experience addressing a general clinical issue (i.e., anxiety) within each of the 50 states. We identified the names of the first 13 licensed clinicians from each state and searched the internet for their email addresses. If an email address could not be found, we replaced this clinician with the next licensed clinician listed on the Psychology Today website for that particular state. We continued this process until we had names and email addresses for 13 licensed clinicians from each state, yielding 650 potential participants.

We calculated a desired sample of 650 given that researchers purported an average response rate of 15.7% for online research surveys sent to professional counselors in the “other” category (members of state-level associations), which most closely reflected our sample (Poynton et al., 2019). After receiving approval from the Institutional Review Board, we emailed the questionnaire link utilizing the Qualtrics software program to the 650 potential participants. Fifty-two emails were undeliverable, resulting in 598 emails sent. We sent participants three reminder emails over the course of three weeks. We received 102 questionnaires (17.1% response rate) from our national sample of licensed clinicians. After removing eight unfinished questionnaires, our final sample consisted of 94 participants (adjusted response rate = 15.7%).


To answer our research questions regarding licensed clinicians’ experiences with client NSSI, we assessed descriptive data resulting from responses to our questionnaire. The data fell into six broad categories: (a) frequency of NSSI in clinical work, (b) descriptions of clients who self-injure, (c) assessment of NSSI, (d) role of the internet, (e) clinicians’ beliefs about NSSI as an addiction and formal diagnosis, and (f) NSSI-related training and perceived competence.

Frequency of NSSI in Clinical Work

     We first sought to examine how frequently licensed clinicians worked with clients who self-injured. Specifically, we asked our sample how often in the totality of their clinical work they addressed client NSSI. Results indicated that only two (2.1%) clinicians had never worked with a client reporting NSSI, 37 (39.4%) addressed NSSI rarely (about 10% of the time), 33 (35.1%) addressed NSSI occasionally (about 30% of the time), 13 (13.8%) addressed NSSI a moderate amount (about 50% of the time), five (5.3%) addressed NSSI frequently (about 70% of the time), and four (4.3%) addressed NSSI almost always (about 90% of the time). Thus, among a national sample of 94 licensed clinicians, 92 (97.9%) reported working with NSSI at some point in their careers, with 55 (58.5%) reporting that they addressed NSSI 30% of the time or more.

We also assessed frequency of NSSI among clients in the past year. Only one (1.1%) clinician reported not having self-injuring clients in the previous 12 months. Fifty-one (54.3%) clinicians worked with 1–5 clients who self-injured, 24 (25.5%) worked with 6–10 clients who self-injured, six (6.4%) worked with 11–15 clients who self-injured, and nine (9.6%) worked with more than 15 clients who self-injured. Three (3.2%) participants did not respond to this item.

Descriptions of Clients Who Self-Injure

We then examined clinicians’ descriptions of clients who reported NSSI. Specifically, we inquired about age, gender, race, and method of self-harm by asking clinicians what portion of their clients who self-injured fell into various categories (Table 1). Sixty-one (64.9%) clinicians reported that most or all of their clients who self-injured were female, five (5.3%) reported that most or all of their clients who self-injured were transgender, and one (1.1%) reported that most or all clients who self-injured were male. With regard to race, 63 (67.0%) clinicians reported that most or all of their clients who self-injured were White and nine (9.6%) clinicians reported that most or all of their clients who self-injured were members of a marginalized racial group. With regard to age, 36 (38.3%) clinicians reported that most or all of their clients who self-injured were adolescents, 31 (33.0%) reported that most or all of their clients who self-injured were adults, and one (1.1%) reported that most or all of their clients who self-injured were children. In terms of method of self-injury, 43 (45.7%) clinicians reported that most or all of their clients who self-injured engaged in cutting and seven (7.4%) clinicians reported that most or all of their clients who self-injured engaged in self-injurious behavior other than cutting (e.g., burning, hitting, scratching, punching). Therefore, the experience of NSSI is diverse. Although a substantial portion of clinicians reported that the majority of clients presenting with NSSI were White female adolescents who engaged in cutting, numerous clinicians indicated some clients (up to 50%) were male or transgender, children or adults, clients of color, and engaged in methods other than cutting.


Table 1

Number of Clinicians Endorsing Each Response


Item: Among your clients who self-injure, what portion are:  None
< 50%)
About half (50%) Most
> 50%)
Female 1 (1.1%) 17 (18.1%) 12 (12.8%) 43 (45.7%) 18 (19.1%)
Male 21 (22.3%) 57 (60.6%) 11 (11.7%) 1 (1.1%) 0
Transgender 39 (41.5%) 37 (39.4%) 9 (9.6%) 3 (3.2%) 2 (2.1%)
White 2 (2.1%) 20 (21.3%) 6 (6.4%) 45 (47.9%) 18 (19.1%)
Person of Color 25 (26.6%) 51 (54.3%) 7 (7.4%) 6 (6.4%) 3 (3.2%)
Children 64 (68.1%) 24 (25.5%)  0 0 1 (1.1%)
Adolescents 19 (20.2%) 22 (23.4%) 15 (16.0%) 31 (33.0%) 5 (5.3%)
Adults 7 (7.4%) 39 (41.5%) 13 (13.8%) 22 (23.4%) 9 (9.6%)
Engaged primarily in cutting 2 (2.1%) 32 (34.0%) 14 (14.9%) 35 (37.2%) 8 (8.5%)
Engaged primarily in self-injurious behavior other than cutting 19 (20.2%) 52 (55.3%) 14 (14.9%) 6 (6.4%) 1 (1.1%)

 Note. Numerical values refer to number of clinicians endorsing that response, followed by percent of clinicians out of the total (N = 94); percentages do not equate to 100 because of missing items: female (missing 3), male (missing 4), transgender (missing 4), White (missing 3), person of color (missing 2), children (missing 5), adolescents (missing 2), adults (missing 4), primarily cutting (missing 3), primarily other behavior (missing 2).


Assessment of NSSI

We also examined data related to the clinical assessment of NSSI. The most commonly endorsed form of assessing NSSI among clinicians was informal assessment through dialogue (n = 83, 88.3%), followed by the use of formal NSSI assessment instruments (n = 21, 22.3%). One (1.1%) clinician reported never assessing NSSI in their clinical work. We also inquired as to whether or not clinicians’ intake forms contained items related to NSSI. Forty-six (48.9%) reported yes, the NSSI item was separate from suicide items; 22 (23.4%) reported yes, the NSSI item was in conjunction with suicide attempts; 16 (17.0%) clinicians reported no, their intake form did not have an item related to NSSI; and 10 (10.6%) did not know or did not answer this question.

Role of the Internet in Client Self-Injurious Behavior

We investigated participants’ responses to items related to clients’ internet use related to NSSI. Specifically, we asked clinicians what portion of their clients engaging in NSSI utilized the internet or social networking sites (SNS) to share pictures of self-injury. Forty-two (44.7%) clinicians reported they did not know because they never discussed the issue with their clients who self-injured. Twenty-six (27.7%) clinicians reported that some (up to 50%) of their clients who self-injured shared NSSI pictures online, 20 (21.3%) reported none of their clients who self-injured shared NSSI pictures online, and three (3.2%) reported that half to all of their clients who self-injured shared NSSI pictures online. In response to the item assessing the frequency in which clinicians asked clients who self-injured about their internet and SNS use related to self-injury, 33 (35.1%) clinicians reported they never asked about this topic, 27 (28.7%) asked sometimes (less than 50% of the time), seven (7.4%) asked about half the time, 17 (18.1%) asked most of the time (more than 50%), and eight (8.5%) always asked. Therefore, it appears that clinicians do not consistently inquire about clients’ internet and SNS use as it relates to NSSI, but those who do find that some of their clients share pictures of self-injury online.

Clinicians’ Beliefs About NSSI

     In light of the current status of NSSI Disorder as a condition for further study in the DSM-5 (APA, 2013) and debate about the addictive nature of NSSI, we asked clinicians to share their beliefs on these two topics. With regard to diagnostic status, 32 (34%) clinicians believed NSSI Disorder should be a formal diagnosis in the next edition of the DSM, 24 (25.5%) did not have a preference, and 13 (13.8%) did not believe it should be a diagnosis. Twenty-five (26.6%) participants did not respond to this item. Pertaining to the conceptualization of NSSI as an addiction, 78 (83.0%) clinicians believed that for some individuals, NSSI can be an addiction; eight (8.5%) did not believe NSSI could be an addiction; six (6.4%) stated they did not know; and two (2.1%) did not answer this item. Thus, it appears that one third of the sample supported a formal diagnosis of NSSI Disorder in the DSM proper and a large majority of the sample agreed that NSSI could be an addictive behavior.

NSSI-Related Training and Competence

Finally, participants reported settings in which they received training to address NSSI in clinical work (participants could select all modalities that applied). The most common training modality was continuing education (e.g., conference presentations, workshops, seminars), which was endorsed by 55 (58.5%) clinicians. On-the-job training was the second most common modality, endorsed by 47 (50.0%) clinicians, followed by graduate school coursework, endorsed by 42 (44.7%) clinicians; self-study, endorsed by 38 (40.4%) clinicians; and graduate school internships, endorsed by 28 (29.8%) clinicians. Three (3.2%) clinicians reported that they had never received NSSI training. Clinicians further reported the extent to which they felt competent addressing NSSI in counseling. Four (4.3%) clinicians felt extremely incompetent, eight (8.5%) felt somewhat incompetent, 10 (10.6%) felt neither competent nor incompetent, 54 (57.4%) felt somewhat competent, and 17 (18.1%) felt extremely competent. One (1.1%) clinician did not respond to this item. Overall, clinicians primarily received NSSI training via continuing education workshops and on-the-job experiences. About half of our sample felt somewhat competent to address NSSI, indicating opportunities to improve NSSI training and competence among clinicians.


Given the rising prevalence of NSSI (Mercado et al., 2017; Wester et al., 2018) and new considerations such as social contagion (Walsh, 2012; Walsh & Rosen, 1985) and sharing NSSI images online (Lewis et al., 2011; Miguel et al., 2017), continued research is needed related to clinical work with self-injury. We disseminated a questionnaire among a national sample of licensed clinicians to examine the prevalence of NSSI, descriptions of clients who engage in NSSI, means of assessing NSSI, role of the internet in NSSI behaviors, clinicians’ beliefs about NSSI, and NSSI training and perceived competence. Our results indicated that most clinicians surveyed (n = 92, 97.9%) have worked with at least one client who engaged in NSSI. This prevalence rate suggests a potential increase in the presenting concern since Trepal and Wester’s (2007) study, in which 81% of practicing counselors reported working with a client who self-injured during their careers. Furthermore, our results revealed that 95.7% (n = 90) of clinicians treated at least one client participating in NSSI within the past year. Although researchers have determined that 8% of adolescents (Barrocas et al., 2012) and 45% of college freshman (Wester et al., 2018) in naturalistic samples engaged in NSSI at some point in their lifetimes, it appears the frequency might be higher among clients seeking counseling services.

Previous researchers have established that NSSI is more prevalent among females than males (Barrocas et al., 2012; Doyle et al., 2017; Mercado et al., 2017). Our results confirmed these findings as 61 (64.9%) of the clinicians in our sample indicated that most or all of their clients who self-injured were female, as compared to only one (1.1%) who said most or all were male. It is important to note, however, the prevalence of clinicians who reported working with male clients who self-injured. Specifically, 57 (60.6%) noted that some of their clients who self-injured were male and 11 (11.7%) reported that about half of their clients who self-injured were male. Thus, these results indicate that although NSSI is more prevalent among females, it also occurs among male populations. Additionally, although NSSI typically begins in adolescence (Nock & Prinstein, 2004; Wester & Trepal, 2017), 31 (33%) of the clinicians in our sample reported that most or all of their clients who engaged in NSSI were adults. It is imperative, therefore, that clinicians who work with both adolescents and adults are prepared to effectively screen for and treat NSSI.

Regarding the assessment of self-injurious behaviors, our results revealed that only 21 (22.3%) clinicians utilized formal NSSI assessments. Although informal assessment measures often are effective, clinicians could benefit from reviewing psychometrically sound NSSI assessment instruments such as the Deliberate Self-Harm Inventory (Gratz, 2001), the Alexian Brothers Urge to Self-Injure Scale (ABUSI; Washburn et al., 2010), or the Non-Suicidal Self-Injury-Assessment Tool (Whitlock et al., 2014; see Wester & Trepal, 2017, for an extensive description of multiple NSSI assessments).White Kress (2003) summarized that clinicians should assess the function, severity, and dynamics of NSSI, including age of onset, emotions while engaging in NSSI, antecedents to NSSI, desire and efforts to stop or control NSSI, use of substances while self-injuring, medical complications, and changes over time.

We also sought to understand the role of the internet and SNS in NSSI behaviors. Specifically, we inquired of licensed clinicians the extent to which their clients utilized the internet or SNS to share NSSI images and the frequency in which they asked clients who self-injured about their internet behavior. According to the results of our survey, almost half of clinicians surveyed (n = 42; 44.7%) did not know about the role of the internet or SNS among clients who self-injured because they did not ask. Twenty-nine (30.9%) clinicians reported that at least some of their clients used the internet to share pictures. Furthermore, 33 (35.1%) of the clinicians in our study disclosed they had never asked about SNS or the internet when assessing and treating clients engaging in NSSI, and 27 (28.7% ) reported asking less than 50% of the time. These numbers indicate a need for clinicians to have access to current research related to the prevalence of viewing and sharing NSSI images online (Lewis et al., 2011; Miguel et al., 2017). For example, Lewis and Seko (2016) thematically examined 27 empirical studies investigating the perceived effects of online behavior among those who self-injure. The authors reported both perceived benefits of online NSSI activity (i.e., mitigation of social isolation, recovery encouragement, emotional self-disclosure, and curbing NSSI urges) as well as perceived risks (i.e., NSSI reinforcement, triggering NSSI urges, and stigmatization of NSSI; Lewis & Seko, 2016). In addition, previous researchers have found that a portion of individuals engaging in NSSI do so to influence others (Doyle et al., 2017; Nock, 2008), and thus may be particularly attracted to sharing NSSI images online. Given the complex role of the internet in self-injury, it seems imperative that clinicians broach the subject with clients who self-injure.

Our results also demonstrated a strong belief among clinicians (n = 78; 83%) that NSSI can be an addictive behavior for some clients, which supports the stance of previous researchers who conceptualize NSSI as a behavioral addiction (Buser & Buser, 2013). The conceptualization of NSSI as an addictive behavior, with particular emphasis on the stimulation of the endogenous opioid system, has important implications for treatment. Evidence-based addictions treatment strategies such as 12-step support group attendance (Connors et al., 2001) and motivational interviewing (Miller & Rollnick, 2013) can be helpful approaches for working with client NSSI.

Finally, we examined clinicians’ training experience and perceived competence related to NSSI. Less than half of our participants (n = 42; 44.7%) received NSSI training in their graduate-level coursework. The number of clinicians seeking NSSI training via continuing education (n = 55; 58.5%) and self-study (n = 38; 40.4%) is indicative of the desire for more knowledge related to self-injury. In addition, roughly 23% (n = 22) of our sample felt less than “somewhat competent” when addressing NSSI in their clinical work. This perceived incompetency reflects the reported lack of training related to NSSI treatment. Ultimately, this data highlights the opportunity to substantially improve NSSI training to increase clinical competence.

Implications for Counselors

The results of the current study have implications for clinical work with NSSI, specifically in the realms of assessment and treatment. Although many clinicians in our study reported effective assessment measures related to NSSI, an important step for improving assessment might be to include a separate NSSI item on intake forms distinct from suicidal behavior. Sixteen clinicians (17%) in our study said their intake form did not inquire about NSSI, and 22 (23.4%) said the item was written in conjunction with suicidal ideation and attempts. The combination of NSSI and suicidal thoughts or ideations on an intake form can make client conceptualization and treatment goals challenging. NSSI and suicide attempts have markedly different motives (Favazza, 1998; Walsh, 2012; Wester & Trepal, 2017); therefore, listing the behaviors as two separate intake items may best serve both clinicians and clients. Specifically, clinicians could provide a definition of NSSI (Favazza, 1998) on the form to help clients understand the terminology. For clients who indicate that they are engaging in NSSI, clinicians can then utilize formal assessment instruments or the proposed NSSI Disorder diagnostic criteria in the DSM-5 (APA, 2013) to gain a thorough understanding of the behavior. Additionally, clinicians may best serve clients by assessing NSSI with all individuals, regardless of gender, age, racial, or ethnic identification, by asking a broad question such as “Have you ever deliberately hurt yourself?” rather than “Have you ever cut yourself?” to be inclusive of multiple forms of NSSI.

With regard to treatment strategies for NSSI, several useful approaches exist. Dialectical behavior therapy (Linehan, 1993) is a counseling method combining cognitive-behavioral and mindfulness techniques for work with clients diagnosed with borderline personality disorder (BPD). NSSI can be associated with BPD given that self-mutilation is listed as a diagnostic criterion for the disorder (APA, 2013). Researchers have found empirical support for the efficacy of dialectical behavior therapy with regard to NSSI (Choate, 2012; Muehlenkamp, 2006); thus, this treatment approach may be useful for clients with BPD and NSSI. Self-injury also can exist apart from a BPD diagnosis (Muehlenkamp, 2005). In these instances, treatment for self-injurious behavior (T-SIB; Andover et al., 2015) may be a useful approach. T-SIB is a 9-week intervention designed for young adults who self-injure. The intervention includes providing psychoeducation, increasing motivation to change, conducting functional analysis, developing replacement behaviors, increasing distress tolerance, and cognitive restructuring (Andover et al., 2015, 2017). Some empirical support exists for the efficacy of T-SIB among young adults, and the treatment manual provides detailed information for clinicians using the approach (Andover et al., 2015, 2017).

Regardless of the therapeutic intervention, it would behoove clinicians to inquire about clients’ online activities related to NSSI to inform treatment plans and goals. Clients’ online activities could include watching NSSI videos; viewing NSSI images; posting and sharing NSSI images on SNS; communicating with others who self-injure via chatrooms and NSSI websites; or seeking information related to how to conceal, clean, or perform NSSI. As part of their recovery plan, it may be helpful for clients and counselors to develop strategies for healthy online behaviors to minimize triggers, urges, or the normalization of NSSI. Even for clients who describe using the internet to find support for their NSSI, clinicians have the opportunity to describe potential risks with NSSI online activity as well (Lewis & Seko, 2016).

Limitations and Future Research

This study is not without limitations. First, our final participant sample consisted of only 94 licensed clinicians, which reflected a 15.7% response rate. Although this is fairly typical for online surveys (Poynton et al., 2019), there were many potential respondents who did not participate, and we were unable to determine if non-respondents differed significantly from respondents. Additionally, in order to obtain a nationally representative sample, we utilized the clinician database found on Psychology Today. Thus, our participants were limited to only those clinicians who registered for that particular website. Furthermore, although our questionnaire was robust, we did not inquire about the nature of internet use among clients with NSSI. Future researchers may choose to assess whether clients primarily use the internet for education related to NSSI, to find support, to share images, or to read others’ accounts of NSSI behaviors. Finally, we utilized only licensed clinicians for this study. Future researchers may choose to replicate this study with specific types of counselors such as school counselors, inpatient counselors, and outpatient counselors to assess experiences with individuals who self-injure. In these various settings, researchers may inquire as to how clinicians code for NSSI, given that it is not included in the DSM-5 proper.


     Nonsuicidal self-injury is a prevalent concern among clients seeking clinical services. We sought to understand clinicians’ experiences working with NSSI by surveying a national sample of licensed practitioners (N = 94). As demonstrated by our results, NSSI affects individuals across age ranges and gender identifications, although it is most prevalent among White female adolescents. Our findings indicate that the majority of clinicians (97.9%) worked with at least one client who engaged in NSSI in the past year. Furthermore, the majority of our sample (83.0%) supported the stance that NSSI can be an addictive behavior. Finally, our study indicates a need for more training related to NSSI in graduate programs and an emphasis on differentiating between NSSI and suicide attempts on intake forms and in clinical work.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Amanda Giordano, PhD, LPC, is an assistant professor at the University of Georgia. Lindsay A. Lundeen, MS, NCC, is a doctoral student at the University of Georgia. Chelsea M. Scoffone, MEd, is a doctoral student at the University of Georgia. Erin P. Kilpatrick, MS, NCC, LPC, is a doctoral student at the University of Georgia. Frank B. Gorritz, MS, NCC, is a doctoral student at the University of Georgia. Correspondence may be addressed to Amanda Giordano, 422G Aderhold Hall, 110 Carlton Street, Athens, GA 30602, amanda.giordano@uga.edu.

Infusing Service Learning Into the Counselor Education Curriculum

Kristen Arla Langellier, Randall L. Astramovich, Elizabeth A. Doughty Horn


Counselors are frequently called upon to be advocates for their clients and, more broadly, to advocate for the counseling profession. However, many new counselors struggle with integrating advocacy work in their counseling practice. This article provides an overview of service learning and identifies ways counselor educators may foster advocacy skills among counselors-in-training through the use of planned service learning experiences in the counselor education curriculum. The authors then provide examples of service learning activities for use within the Council for Accreditation of Counseling and Related Educational Programs (CACREP) 2016 core curricular areas, including professional orientation and ethical practice, social and cultural diversity, career development, helping relationships, and group work. 

Keywords: advocacy, service learning, counselor education, ACA, CACREP


University faculty members frequently include service learning experiences in the undergraduate curriculum as a means for helping prepare students to develop as community members through meaningful civic engagement experiences that are augmented with classroom education (Servaty-Seib & Tedrick Parikh, 2014; Stanton & Wagner, 2006). Unfortunately, service learning assignments tend to diminish significantly as students make the transition from undergraduate to graduate education (Jett & Delgado-Romero, 2009; Servaty-Seib & Tedrick Parikh, 2014; Stanton & Wagner, 2006). Much of the existing scholarly literature centers around the impact of service learning on students who are at a traditional undergraduate age (Jett & Delgado-Romero, 2009; Servaty-Seib & Tedrick Parikh, 2014). The lack of service learning opportunities in the graduate curriculum is surprising, given that service learning may help students develop a deeper sense of community, appreciate others’ perspectives, and identify avenues for contributing to social change (Cipolle, 2010).

Within graduate counselor training programs, counselor educators could more frequently utilize service learning projects (SLPs) in order to enhance knowledge of diverse community cultures among counselors-in-training (CITs) as well as provide CITs with opportunities to assess community needs and implement advocacy efforts. The counseling profession’s Multicultural and Social Justice Counseling Competencies (MSJCC), revised in 2016, states the importance of “integrating social justice advocacy into the various modalities of counseling” (Ratts et al., 2016, p. 31). In addition, the MSJCC posits that counselors and counselor educators conceptualize clients through a socioecological lens so as to understand the social structures affecting their world. Service learning curricula often include a social justice focus, which has been demonstrated to help students understand the structures in place that oppress others (Tinkler et al., 2015). With these guidelines in mind, the purpose of this article is to provide practical suggestions to help counselor educators infuse service learning into their curriculum, thus offering CITs more opportunities for personal and professional development.

Service Learning

Service learning was first introduced in the early 1900s as a method for fostering academic and social learning and advancements for students via community involvement (Barbee et al., 2003). Bringle and Hatcher (1995) defined service learning as

a credit-bearing, educational experience in which students a) participate in an organized service activity that meets identified community needs, and b) reflect on the service activity in such a way as to gain further understanding of course content, a broader appreciation of the discipline, and an enhanced sense of civic responsibility. (p. 112)

Since its inception, many disciplines have found service learning useful as a method of merging the academic with the practical; it has become popular with disciplines such as nursing (Backer Condon et al., 2015), teacher education (Tinkler et al., 2015), and public health (Sabo et al., 2015).

With respect to counselor education, there has been a diminutive amount of research related to the implementation and effectiveness of service learning. In 2009, Jett and Delgado-Romero described service learning as an area of developing research in counselor education, and this could still be said today. There is a paucity of literature regarding service learning in graduate education (Servaty-Seib & Tedrick Parikh, 2014) and, more specifically, within counselor education. Yet university faculty, particularly counselor educators, are tasked with the challenge of bridging academic theory and research with “real-world” experiences. Therefore, SLPs may serve as a method for students and faculty to connect with the community in which they live and beyond (Nikels et al., 2007).

After reviewing service learning literature, Dotson-Blake et al. (2010) determined successful SLPs contain five essential characteristics that contribute to the overall intention of service learning. They contended successful SLPs should be developed in concert with a community or professional partner, contain coherent and well-defined expectations, incorporate stakeholder support, consider students’ developmental levels, allow ample opportunity for reflective practices, and broaden or expand because of the impact of the project (Dotson-Blake et al., 2010). Focusing on the above underpinnings of successful SLPs could potentially assist counselor educators in the planning and implementation stages of these sorts of projects, as they can take time and considerable effort to develop.

Service Learning and Social Justice

According to Cipolle (2010), social justice and service learning are interrelated. She asserted that service learning and social justice need to be considered together so as to accomplish a larger goal of connection with the community. An additional component to service learning is the development of critical consciousness. Students engaging in service learning as a means of social justice may gain compassion and understanding from their participation (Cipolle, 2010). A by-product of service learning with a social justice focus may be the development of self-awareness through students’ opportunities to see for themselves how others live their lives; perhaps students will also see the impact of the dominant culture (Cipolle, 2010). Self-awareness is a key component of the 2016 MSJCC (Ratts et al., 2016) and is found throughout the Council for Accreditation of Counseling and Related Educational Programs (CACREP) 2016 Standards (CACREP, 2015). Additionally, the ACA Code of Ethics asserts that counselors should ascribe to self-awareness to maintain ethical practice and reflection (American Counseling Association [ACA], 2014).

Service Learning Versus Community Service

An important distinction between community service and service learning lies within the beneficiaries of each. Within community service, the beneficiaries are those receiving the service. Service learning posits a reciprocal model, with both the recipient of service and student benefitting from the project (Blankson et al., 2015). Thus, SLPs provide students with opportunities to be exposed to issues of social justice that may foster empathy and cultural self-awareness. Students can benefit from service learning as it may assist them in developing increased compassion for others (George, 2015). With the continued focus on social justice within many disciplines, SLPs may provide another avenue for counselor educators to help students more fully understand the diverse needs of their communities and advocate for the underserved.

Throughout participation in an SLP, and at the completion, students are encouraged to apply critical thinking to their efforts and reflect on progress, barriers, and benefits (Blankson et al., 2015). For successful service learning to occur, projects should be connected to specific course objectives. Such a curricular emphasis is not generally a component of community service initiatives. By combining student projects and course material, instructors are able to help students solidify course material into practical applications (McDonald & Dominguez, 2015). This experiential avenue may appeal to non-traditional learners and provide more integration of material than didactic coursework alone (Currie-Mueller & Littlefield, 2018).

Effects of Service Learning

     Cipolle (2010) reported that students participating in early service learning received numerous benefits, including having higher self-confidence, feeling empowered, gaining self-awareness, developing patience and compassion, recognizing their privilege, and developing a connection and commitment to their community. All of these outcomes are consistent with the aims and goals of standards, competencies, and codes of ethics within the counseling profession (ACA, 2014; CACREP, 2015; Ratts et al., 2016).

Scott and Graham (2015) reported an increase in empathy and community engagement for school-age children when participating in service learning. They also reported that several previous works measured similar favorable effects among high school– and college-age individuals. Because of these overlapping desired effects and the need to incorporate social justice throughout the curriculum, service learning would fit well into current models of counselor education.

Service Learning Efforts in Counselor Education

The ACA Code of Ethics (2014) calls upon professional counselors to donate their time to services for which they receive little to no financial compensation. The incorporation of SLPs could provide an opportunity to fulfill this ethical obligation while training students and connecting with the community. A dearth of literature exists as to specific counselor education service learning efforts. Of the few results, many are focused on pre-practicum level SLPs (Barbee et al., 2003; Jett & Delgado-Romero, 2009), pedagogical tools woven into the multicultural and diversity-based courses (Burnett et al., 2004; Nikels et al., 2007), and group leadership training (Bjornestad et al., 2016; Midgett et al., 2016). Alvarado and Gonzalez (2013) studied the impact of an SLP on pre-practicum–level counseling students and found that students reported an increase in their confidence in using the core counseling skills and a deeper connection with the community outside of the university setting. Havlik et al. (2016) explored the effect SLPs had on CITs and found similar themes to Alvarado and Gonzalez, particularly that of raised levels of confidence in the ability to use the core counseling skills.

In other counselor education–related studies, researchers also reported positive impacts of service learning. One such impact was that of raised student self-efficacy (Barbee et al., 2003; Jett & Delgado-Romero, 2009; Murray et al., 2006). An added and practical benefit for students has also been a greater understanding and familiarity of the roles and settings of professional counselors and a deepened understanding of counselors’ roles within professional agencies. Students were able to examine their own professional interests prior to practicum work and participate in valuable networking experiences with other professionals (Jett & Delgado-Romero, 2009).

An increased compassion for the population with whom they work has been reported (Arnold & McMurtery, 2011) as a result of service learning. Burnett et al. (2005) reported increased counselor self-awareness, which is an important component of counselor education, regardless of delivery method, program accreditation, or instructor pedagogy. They also reported a component of a successful service learning course to be peer-learning. Peer-learning involves the giving and receiving of feedback, and this provides a foundation for experiences of group supervision feedback later in counseling programs (Burnett et al., 2005). A frequent reported result of participation in service learning has been increased multicultural competence and social justice awareness on the part of the student (Burnett et al., 2004; Lee & Kelley Petersen, 2018; Lee & McAdams, 2019; Shannonhouse et al., 2018). In short, the incorporation of SLPs would benefit counselor educators in developing desired qualities in beginning counselors while giving them opportunities to network and more fully integrate material.

Integrating Service Learning Into Counselor Education

Freire (2000) espoused that education should inspire students to become active and engaged members of the classroom in order to develop a deeper critical consciousness of society. Keeping Freire’s goal in mind, counselor educators could utilize service learning to bridge the divide that exists between the “ivory tower” and communities outside of academia. Counselors are called to apply their theoretical knowledge to real-world clients and to be advocates for those whose voices are silenced because of various forms of oppression (ACA, 2014; CACREP, 2015; Ratts et al., 2016). Through participation in SLPs, students are able to see firsthand the effects of oppression and assist with creating solutions; often, the projects chosen contain an element of social justice (George, 2015). Furthermore, SLPs woven into coursework may provide the opportunity for students to begin finding their voices as advocates and activists in a supportive environment, where peers are available to assist with potential problems that may arise.

By encouraging CITs to participate in SLPs earlier and often within their graduate education, students may have more opportunities to engage with diverse populations and to experience community environments and sociopolitical influences faced by different groups. The focus of clinical work during the practicum and internship phases of counselor education typically emphasizes counselor skill development and client progress rather than community-focused perspectives (Barbee et al., 2003; Jett & Delgado-Romero, 2009). Thus, by incorporating SLPs into regular coursework, students may feel freer to engage holistically in a community system rather than focus narrowly on their own counseling skill development and individual client progress. For all SLPs, there is the potential for students to experience the project components as challenging to complete. In this situation, students may be redirected to identify and analyze barriers to the success of the project and to identify strategies for eliminating those barriers.

Gehlert et al. (2014) argued that SLPs can also serve as potential gatekeeping tools. They posited that by engaging with individuals outside of the classroom experience, especially earlier than the practicum stage, students might decide for themselves that the counseling profession is not the right choice for their career (Gehlert et al., 2014). They further contended that utilizing SLPs early in students’ programs of study will allow the opportunity for faculty to identify students who might be in need of remediation plans before they are working with clients (Gehlert et al., 2014).

Counselors are urged to be advocates for the profession and for clients (ACA, 2014). Service learning may function as a natural initiation into that identity (Manis, 2012; Toporek & Worthington, 2014) and could possibly provide a bridge between an identity as a counselor and that of a counselor advocate. Another potential benefit of service learning is that students may be able to gain knowledge as to the realities of the profession beyond specific contact hour requirements to satisfy internship and licensure requirements. This could prove helpful as a gatekeeping tool as well. Students who find themselves disliking significant aspects of the profession might choose to leave the program without requiring faculty intervention.

Experiences of SLPs can be distilled into poster presentations or conference presentations. In this context, SLPs benefit both CITs and counselor educators, as professional development can occur for both. For students, conferences can be valuable networking opportunities, and for counselor educators, conference-related activities fall under required professional development (ACA, 2014; CACREP, 2015). Experiences could also serve as the foundation for manuscripts and research projects, both of which are considered professional development.

Service Learning Opportunities Within Specific Counseling Content Areas

CACREP (2015) provides counselor educators with standards for training that can be used to facilitate course development, learning objectives, and class assignments. Several core content areas within a CACREP-aligned counseling curriculum may offer instructors and students the chance to engage in SLPs. Because little information currently exists regarding best practices for service learning within counselor education, the authors created example SLPs that are based on CACREP standards and rooted in the relevant content area literature. These are designed to facilitate the development of advocacy skills in a variety of environments. It should be noted that with any SLP, it is important for counselor educators to engage in continued monitoring of projects and student placements. Given that SLPs provide a reciprocal benefit for both students and the community, it is important to ensure everyone involved is experiencing ongoing added value. Therefore, counselor educators are encouraged to create and maintain relationships with stakeholders for feedback throughout the SLP and to make adjustments as necessary.

Professional Orientation and Ethical Practice

Licensure remains an important topic within the counseling profession (Bergman, 2013; Bobby, 2013) and professional counselors are now able to obtain licensure in all states (Bergman, 2013; Urofsky, 2013). In order to become more familiar with state licensure policies and procedures, an SLP might involve student interviews with a member of the state licensure board and reflection upon that experience through a written journal entry. Questions posed to the board member could range from the practical aspects of obtaining a license in their state to the broader implications of ethical issues the board encounters. Student findings could then be utilized to develop a project involving the entire class in which students brainstorm ideas about what assistance the board might need in terms of outreach or advocacy. Examples could include barriers to licensure because of cost or English as a second language (making the testing aspect of obtaining licensure difficult). Students and faculty could use class time deciding what action to take and then implement and assess their plan.

Another example of an SLP that falls under this core content area is for students to volunteer time (e.g., 6 hours or more over a semester) assisting their state branch of ACA. An important aspect of the profession of counseling is involvement with relevant policy and legislation (Bergman, 2013). Students interested in getting involved in this area could spend time working with the lobbyist for their state’s ACA branch (provided the state has retained a lobbyist) in order to assist them in advocating for the profession. Simple tasks such as assisting with office work can be of significant help to one working in a high-stress position and can prepare students for the realities of clinical work. State and federal government have a significant role in shaping the profession (Bergman, 2013), and because of this, counselor educators can utilize service learning in order to inspire students to become involved early in their careers.

Should the state ACA branch not have retained a lobbyist, students can work with branch leadership in order to determine barriers. Perhaps costs are prohibitive, in which case students could help with fundraising efforts and outreach. Encouraging master’s students to take interest in policy and legislation pertaining to the profession will give them the foundation for making meaningful change and assisting with social justice efforts (Cipolle, 2010; Bergman, 2013).

Social and Cultural Diversity

Much of the existing literature regarding service learning and counselor education focuses on social and cultural diversity with regards to SLPs (Burnett et al., 2004). Philosophically, SLPs align with the aims and scope of the MSJCC (Ratts et al., 2016). Frequently, course assignments contain a cultural immersion project in order for counselors to encounter experiences in which their personal values might cause a conflict when working with clients (Burnett et al., 2004; Canfield et al., 2009). Service learning experiences could easily augment the student learning process within multicultural or diversity courses by helping students experience cultural immersion, which may foster greater compassion, empathy, and cultural sensitivity (Cipolle, 2010; Burnett et al., 2004).

One possibility for a social and cultural diversity–focused SLP would involve students working at a shelter for homeless populations or a center for refugees. Students could also find an organization that serves a minority or oppressed population and partner with them to help fill a need they are experiencing. Students would therefore gain experience working with people from groups with whom they may have limited prior experience. This can assist with students identifying their own privileges prior to working in the counseling setting. Ideally, students would contact the shelter or center at the start of the semester in order to ascertain the exact needs of the agency.

An additional SLP could focus on assisting an organization that advocates for minority or oppressed populations. This also emphasizes gaining experience with diverse populations; however, students would have more freedom in choosing the specific population and could gain more experience in understanding the systems involved in advocacy work. Ideally, the instructor would encourage students to choose organizations in which the student is challenged by their privileges (e.g., not being identified as a member of the population served). Through this project, students have the opportunity to work with a wider variety of individuals and help to bring about social change via their specific project goals. For instance, students could choose a women’s health center that has experienced a decline in attendance. The students might investigate and discover a particular city bus route was discontinued, making transportation to the health center difficult for residents. Students might then partner with various organizations with van access (such as churches) and raise money for weekly transportation in and out of the area.

Career Development

Within the career development area of the CACREP core curriculum, students have the possibility of learning about their own careers and the impact careers have on the lives of clients. Examples of SLPs can include opportunities for students to immerse themselves within various aspects of career development. Several SLPs could come from partnering with a local employment agency. Students could discover barriers to employment for members of the local community and implement a project to alleviate some of those barriers. For example, students might discover a lack of late-night childcare in their community, which affects those working during the evening and night. They might implement a project in which university students provide childcare for a reasonable cost to the parents, making finding employment easier. If liability issues make this too difficult, students could focus their attention on fundraising to hire more qualified individuals to provide the childcare.

As mental health and wellness are primary foci of professional counselors (ACA, 2014; CACREP, 2015), a second potential SLP assignment related to career development could be for students to partner with a local business and provide mental health and wellness screenings, and education via seminars or workshops. Ideally, students would familiarize themselves with the company insurance (or lack thereof) and prepare referrals and resources accordingly. Workshops and seminars could be an avenue for educating employees and the community at large about wellness, prevention, and good mental health. These could be delivered via “brown bag lunches” or more formal trainings for employees.

Helping Relationships

As CITs progress though counselor education programs, it might be helpful for them to discover new ways to employ their skills in helping relationships outside of counseling sessions. Much of the aforementioned scholarship exploring service learning within counselor education discovered an increase in self-efficacy with respect to core counseling skills as a result of participating in SLPs (Alvarado & Gonzalez, 2013; Havlik et al., 2016). An SLP suitable for this core curriculum could be to partner with a suicide prevention agency and provide assistance where needed. For example, students might work on a suicide hotline or provide referrals for people in distress, utilizing their relationship-building skills and reflective listening while learning about suicide assessment or prevention efforts within the community. Of course, it is important to consider students’ level of development and readiness to work with individuals who are suicidal. Counselor educators should ensure there are appropriate supports and supervision for students in these settings. A related project could be for school counseling students to partner with such an organization to create a developmentally appropriate suicide education presentation for high school–age children and deliver it to area schools.

Another SLP focused on the helping relationship might involve students seeking non-counseling placements at local counseling agencies or private practice settings. Ideally, students would have the opportunity to immerse themselves in many elements of practice without having a focus on accruing direct client contact hours. Spending time at an agency before practice might provide students with opportunities to learn many aspects of the profession and the operations of the agency, which in turn could help students decide within which settings they would like to work. This project might also help inform students about potential barriers clients might face in accessing services. They could develop a plan for removing the barriers, which might include identifying potential sources of funding for the project (e.g., grants, scholarships, community donations) and providing an outline of how to access this funding. Another potential benefit to this project is that it could provide students with the opportunity to network within the local counseling community and connect agencies with potential interns.

Group Work

SLPs that correspond to group work can be similar to those under the helping relationships core curriculum. For example, students could partner with a local counseling agency that provides group counseling services. Students could determine if clients encounter any barriers to receiving group counseling and implement a plan for eliminating the barrier(s). A further example is perhaps if the agency has a group in which they would like to see more culturally relevant topics used in order to attract a more diverse group of clients. Students partnering with this agency could perform outreach to discover what clients would like to see at the group and any barriers, such as transportation, to attending this group. Another possibility for an SLP is for students to facilitate a group counseling experience for an agency or shelter for no cost to those participating in the group.


SLPs have the potential to enhance the learning experiences of students within graduate counselor education programs. Although not previously emphasized within counselor training, SLPs may be developed and implemented within a variety of core counseling content areas as suggested by CACREP (2015). From an advocacy and social justice perspective, SLPs also may provide students with multiple opportunities to experience the needs of clients and identify barriers to providing counseling services with diverse client populations. Ultimately, by utilizing SLPs, counselor educators can help foster CITs’ advocacy and social justice identities, preparing them for work as responsible citizens and effective counselors.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Kristen Arla Langellier, PhD, NCC, is an assistant professor at the University of South Dakota. Randall L. Astramovich, PhD, LCPC, is an associate professor at Idaho State University. Elizabeth A. Doughty Horn, PhD, LCPC, is a professor at Idaho State University. Correspondence may be addressed to Kristen Langellier, Division of Counseling and Psychology in Education, University of South Dakota, 414 E. Clark St., Vermillion, SD 57069, kristen.langellier@usd.edu.

Counselors’ Perceptions of Ethical Considerations for Integrating Neuroscience With Counseling

Chad Luke, Eric T. Beeson, Raissa Miller, Thomas A. Field, Laura K. Jones

As with many advancements in science and technology, ethical standards regarding practice often follow innovation. The integration of neuroscience with counseling is no exception, as scholars are just beginning to identify important ethical concerns related to this shift in the profession. Results of an inductive thematic analysis exploring the perspectives of 312 participants regarding the ethics of integrating neuroscience with counseling are presented. This study is the first of its kind to explore mental health counselors’, counselors-in-training’s, and counselor educators’ perceptions of neuroscience integration. The researchers identified a continuum of concern ranging from no concerns to grave concerns. In addition, they identified four specific ethical quandaries: a) neuroscience does not align with our counselor identity, b) neuroscience is outside the scope of counseling practice, c) challenges with neuroscience and the nature of neuroscience research, and d) potential for harm to clients. Implications include four key considerations for counselors prior to proceeding with integrating neuroscience into practice.

Keywords: neuroscience, integration, counselor identity, ethics, counseling practice


The integration of neuroscience with the mental health professions continues, and with this expansion comes the risks associated with any nascent area of innovation (Luke et al., 2019). Neuroscience integration, as used herein, is understood using Beeson and Field’s (2017) definition of neurocounseling, a synonym for the integration of neuroscience with counseling:

A specialty within the counseling field, defined as the art and science of integrating neuroscience principles related to the nervous system and physiological processes underlying all human functioning into the practice of counseling for the purpose of enhancing clinical effectiveness in the screening and diagnosis of physiological functioning and mental disorders, treatment planning and delivery, evaluation of outcomes, and wellness promotion. (p. 74)

Counselors and the counseling profession, under code C.2.b of the American Counseling Association’s ACA Code of Ethics (2014), are charged with scrutinizing innovations and specialty areas prior to and throughout their use in clinical practice; this is a safeguard to protect clients from risky or poorly evidenced theory or practices. For example, some of these risks, as they pertain to neuroscience (i.e., the study of the brain and central nervous system) and neurobiology (i.e., literally, the biology of the neurons and the nervous system), include accuracy, embellishment, misapplication, and hype (Beeson & Field, 2017; Kim & Zalaquett, 2019; Luke, 2016).

The first and perhaps most salient ethical concern in terms of counseling values is that neuroscience integration is not a unilaterally benevolent addition to counseling (Luke, 2019). Although limited research has focused specifically on mental health counselors, several authors have closely examined the effects of using neurobiological language and frameworks to explain and understand mental health disorders in other mental health fields (Fernandez-Duque et al., 2015; Haslam & Kvaale, 2015; Lebowitz et al., 2015; Luke et al., 2019; Nowack & Radecki, 2018). Haslam and Kvaale (2015) summarized the literature on the effects of brain-based explanations of mental health conditions, such as schizophrenia and depression. Their findings challenge long-held notions that biogenic and neurobiological explanations for mental health and psychopathology are singularly positive. The larger assumption in the profession has been that biomedical explanations can reduce self-blame and public shaming of individuals with substance use and other mental health disorders (Badenoch, 2008; Lebowitz & Appelbaum, 2017). Unfortunately, these biological explanations can at times carry unintended consequences that operate against this positive outcome. Clients may be less likely to invest in psychosocial treatments, believing that while on the one hand their biogenic (i.e., brain-based) condition (e.g., depression) is not their fault, it is also therefore out of their control (Lebowitz & Appelbaum, 2017). In other words, one risk of these biological explanations is that they may reduce outcome expectancy with counseling, while increasing the belief that only biological-based treatments (e.g., psychotropic medication) will work for them.

Mental health providers also seem to be similarly affected by these biased perceptions, at times experiencing less empathy for clients in cases framed as neurobiologically based (Lebowitz & Ahn, 2014). Lebowitz et al. (2015) demonstrated that these negative effects could be mitigated somewhat through training. However, Haslam and Kvaale (2015) asserted that it is imprudent to believe that training is sufficient, because “it is unlikely that all of the ill effects of biogenetic explanation can be reversed simply by educating laypeople about bioscience, or that the fundamental problem is their ignorance of neuroplasticity and epigenesis” (p. 402). It is notable that the research above did not include mental health counselors, so the extension of these concerns to counselors remains uncertain. Nevertheless, the concerns seem warranted regarding the allure of neuroscience conceptualizations (Beeson & Miller, 2019; Field et al., 2019; Luke, 2020). Fernandez-Duque et al. (2015) demonstrated how easily humans can be deceived based on the use of the “prestige of science” hypothesis (p. 926). In a series of experiments, the authors used superfluous neuroscientific jargon and images to fool participants into viewing the content as more veracious. Additionally, concerns about the encroachment of science-based reductionism on the humanistic ethos of counseling has begun to resound through the counseling literature (Beeson, Field, et al., 2019; Beeson & Miller, 2019; Field, 2019; Luke, 2019; Luke et al., 2018). Wilkinson (2018) offered a review of the threats of neuroscience to counseling by highlighting the perceived superiority of objective brain-based methods over the humanistic principles of the counseling profession.

Nowak and Radecki (2018) introduced a special issue in the Consulting Psychology Journal: Practice and Research focused on “neuro-mythconceptions.” The authors explored the many ways that neurobiology might be exploited by professionals to justify their current practices. Their concern centered on how plausible neuroscience-based claims can sound. Such plausibility results in professionals passing along dubious information to clients in the name of cutting-edge advances in optimizing human performance. The risk of neuromyths also have been cited in the professions of counseling (Beeson, Kim, et al., 2019; Kim & Zalaquett, 2019) and education (Dekker et al., 2012; Deligiannidi & Howard-Jones, 2015; Gleichgerrcht et al., 2015; Karakus et al., 2015; Macdonald et al., 2017; Papadatou-Pastou et al., 2017; Simmonds, 2014).

Purpose of the Present Study

The potential concerns identified above highlight the need to consider potential ethical implications of counselors integrating neuroscience within their practice. Although ethical concerns regarding the implementation of neuroscience have been referenced anecdotally in conceptual reviews (e.g., Beeson & Miller, 2019; Field, 2019; Luke, 2019; Wilkinson, 2018), no studies were found that explored concerns of the counseling community regarding the broader ethical assumptions about the integration of neuroscience with practice. Therefore, this research is the first to empirically address this critical gap by eliciting the counseling community’s perceptions of ethical concerns related to the integration of neuroscience and counseling. The research question guiding this study explored if counselors perceive ethical concerns pertaining to integrating neuroscience with their counseling practice, and if so, the nature of these concerns.


This study utilized a survey-based qualitative methodology to explore counselors’ perceived ethical concerns regarding the integration of neuroscience with their counseling practice (Merriam & Tisdell, 2016). A single open-ended survey question was selected for qualitative data analysis in this study. This question was part of a larger survey examining counselor perceptions of neuroscience and neuroscience integration with counseling. Given the exploratory nature of the study and the current status of neuroscience literature in the counseling profession, a thematic analysis of a single item from a larger survey was chosen. This methodology was best suited to obtain a general, broad understanding of the concerns within the profession. Use of thematic analysis is consistent with other research in which a standardized measure of the construct (i.e., ethical integration of neuroscience with counseling) does not exist (Bengtsson et al., 2007; Donath et al., 2011). A total of 458 participants completed the larger survey, with 312 participants (67.9%) responding to the question, “What ethical concerns do you have regarding the integration of neuroscience into clinical practice (if any)?”


Integration of neuroscience with counseling practice affects multiple professional roles within the counseling profession. As such, the survey was developed for counselors, counselor educators, and counselors-in-training. We sought to gain responses from counseling practitioners, counselor educators and supervisors, and current master’s- and doctoral-level counseling students. Inclusion criteria for the study consisted of at least one of the following: (a) being licensed as a counselor, (b) belonging to a professional counseling organization, (c) being a current student in a counseling program, or (d) being a current faculty member in a counseling program. Participants who did not meet one of these four criteria were excluded from the study.

Participants varied in their educational attainment, with the highest percentage of participants having graduated with their master’s degree and not pursued doctoral study (35.3%, n = 110). This group was followed by master’s-level students (27.2%, n = 85), doctoral-level graduates (22.1%, n = 69), and doctoral-level students (15.4%, n = 48). Most of the sample (81.4%, n = 254) had attended programs accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP). Many participants (60.9%, n = 190) reported they were exposed to neuroscience in their graduate programs.

The majority of doctoral-level graduates (85.5%, n = 59) were full-time faculty members in counselor education programs. The other 10 doctoral-level graduates were either administrators of clinics, working in private practice, or retired. Of those 59 faculty members, 62.7% (n = 37) provided direct counseling services within the past year. In comparison, 81.0% (n = 205) of the non-faculty participants provided direct counseling services in the past year. When combined, the majority of the sample (77.9%, n = 243) provided direct counseling services within the past year.

The mean number of years of counseling experience was 10.13 years, with a large amount of variance (SD = 10.87). The range for years of experience was 0 to 40 years. Doctoral graduates had the most years of experience on average (M = 19.91, SD = 11.04). They were followed by master’s graduates who were not pursuing doctoral study (M = 11.70, SD = 10.42), doctoral students (M = 7.29, SD = 5.21), and current master’s students (M = 1.74, SD = 4.98). A subset of the sample comprised full-time counselor educator faculty (18.9%, n = 59). Faculty members in the study had more counseling experience (M = 17.83 years, SD = 11.00) than non-faculty participants (M = 8.33, SD = 10.04). No age differences existed by education level. The mean age for the sample was 42.55 years (SD = 13.66) with a range from 21 to 82 years.

Approximately half (54.5%, n = 170) of participants were currently licensed as counselors or psychologists. In addition, 31.1% (n = 97) held the National Certified Counselor (NCC) certification. The majority of the sample (87.5%, n = 273) were members of counseling associations. Participants self-reported their gender identity, racial/ethnic identity, age, and number of years of counseling experience. The sample consisted of 73.3% (n = 229) females, 25.0% (n = 78) males, 1.0% (n = 3) non-binary, and 0.6% (n = 2) transgender. One person did not report gender identity. The survey gave participants the option to report multiple racial/ethnic identities. Fifteen percent of participants (n = 48) identified as multiracial, whereas 84.6% identified as Caucasian/White (n = 264, of which 45 were multiracial). Of the remaining participants, 8.0% identified as Asian or Asian American (n = 25, of which 19 were multiracial), 5.4% as African American/Black (n = 17, of which 13 were multiracial), 3.8% as Hispanic or Latinx (n = 12, of which 10 were multiracial), 1.0% as American Indian or Alaskan Native (n = 3, of which three were multiracial), and 0.3% as Arab/Arab American (n = 1, of which zero were multiracial). No participants identified as Pacific Islanders.


The question addressed in this article was drawn from questions used in a larger study that explored training and attitudes related to neuroscience and counseling. The question used in this study was included intentionally as a means to gain a better understanding of perceptions of the ethics of neuroscience integration, recognizing it as a stand-alone construct for the purposes of analysis. The full survey was constructed by the authors, following a thorough review of the literature around the integration of neuroscience in counseling. All survey questions were constructed to conform to Patton’s (2015) conventions and recommendations for qualitative questions, such as using open-ended and neutral questions, asking one question at a time, and avoiding “why” questions. The specific question analyzed and presented in this report was “What ethical concerns do you have regarding the integration of neuroscience into clinical practice (if any)?”

We utilized convenience and snowball sampling to recruit participants, which makes calculating response rate difficult. However, as the purpose of the project was exploratory and the method qualitative, the participants were not intended to be fully representative. The potential response bias inherent to this study could mean that participants were aware to some degree of the status of the profession with regard to integrating neuroscience into clinical practice, both positively and negatively. Following IRB approval, the authors electronically distributed the Survey Monkey–created online survey to the following: neuroscience interest networks in counseling, the counselor education listserv, CESNET-L, and direct emails to colleagues for distribution. A link to the informed consent and full questionnaire was included in the email. Interested participants clicked on the link and were asked to give their consent in order to continue to the survey. Three separate requests for participants were disseminated, with each request coming 2 weeks apart. Participants who completed the survey in full had the option of submitting their email in a separate survey to be included in a drawing for two signed copies of neuroscience in counseling texts.

Role of the Researchers

To limit unconscious bias in the research process, we engaged in discussions throughout survey development, data collection, and data analysis. Such conversations detailed our respective passions, assumptions, histories, and visions of the profession. Several prior assumptions emerged in this recursive process. These ethical concerns largely mirrored the issues raised in existing literature and described in the introduction section of this article. The primary assumption included the belief that incorporating neuroscience into counseling is a largely positive endeavor but that counselors should follow ethical guidelines outlined by professional counseling organizations to avoid ethical concerns related to integration. One author explicitly assumed that participants would generally default to the ACA Code of Ethics in their response, such that responses might begin with, “According to the ACA Code of Ethics regarding new specialty areas of practice. . . .” One author assumed that most participants would preface their response with “It depends on what you mean by ‘integration’” because integration was intentionally undefined in the survey. We continually challenged and actively reflected on these assumptions in order to understand the impact on the authors’ relationship with the data and subsequent themes (Hays et al., 2016; Hunt, 2011). We also engaged in reflective writing, particularly through writing memos (Hunt, 2011), in order to maintain awareness of worldviews and potential for bias in coding. Commonly referred to as reflexivity, this process aided in being transparent about assumptions rather than trying to behave as if any researcher would be able to be free from biases in approaching a set of data (Hays et al., 2016). Additionally, we established an electronic audit trail that enabled returning to the data, tracking the process, and checking that the coding remained close to the words of the participants. Lastly, two of the authors served as auditors for the results, having familiarized themselves with the data, but refraining from engagement in analysis and theme development.

Data Analysis

We selected thematic analysis, grounded in a pragmatist framework (Duffy & Chenail, 2008), to guide the inquiry into perceptions regarding the ethics of integrating neuroscience and counseling. Clarke and Braun (2017) defined thematic analysis as “a method for identifying, analyzing, and interpreting patterns of meaning (‘themes’) within qualitative data” (p. 297). We reviewed literature related to content analysis and thematic analysis and found that there was significant overlap (and sometimes merging) of the two approaches in published literature. Our best understanding of the two related approaches is that they exist on a continuum, with content analysis stopping at the manifest level of analysis and thematic analysis continuing to identify broader meanings. Although we stayed very close to the participants’ responses in coding, we did move beyond content analysis “categories” to extract some inductive-level themes across cases.

We followed Braun and Clarke’s (2006) six-phase framework, utilizing an inductive and semantic approach to thematic analysis. Braun and Clarke described these connected approaches to analysis as “a process of coding the data without trying to fit it into a preexisting coding frame, or the researcher’s analytic preconceptions . . . themes are identified within the explicit or surface meanings of the data” (pp. 83–84). Given that the data were obtained through an open-ended survey question versus an in-depth interview protocol that could capture greater context and meaning, we aimed to stay close to participants’ exact words. In this way we resisted the urge to include guesses at participants’ motivations or assumptions as part of themes. The emergent codes and themes reflect an inductive, descriptive account of participants’ perceptions. We followed the subsequent steps in analyzing the data.

The first three authors served as members of the coding team for data analysis. We first familiarized ourselves with the data by reading all responses through several times and taking notes on general observations and personal reactions to the data (Braun & Clarke, 2006). Afterward, we met via videoconferencing and looked at all the responses together, line by line, to begin identifying initial codes. The average length of responses was one to two sentences; the range of responses was from one word to over 200 words (a paragraph).

We then searched for patterns in the data, noting frequently used words and phrases and commonly expressed ideas. Fourth, we identified connections and grouped codes into preliminary themes. In doing so, we further expanded the overarching themes into subthemes, capturing some of the nuance represented in participants’ responses. We discussed and resolved differences in coding data via consensus.

Fifth, we reviewed the preliminary themes in light of the raw data and the research question, paying particular attention to our own perspectives and values. The third author re-read each participant response and matched each response to one of the theme groups. Parts of responses at times fell into different theme groups. For example, one participant wrote, “Ethical concerns would be keeping into consideration what the clinician’s scope of practice is, the potential for any side effects or results of rapid growth and brain training, and what insurance companies will cover.” The first part was coded in theme 2 (scope of practice) and the second part was coded in theme 4 (potential harm).

The first and second authors worked with the codes and themes in a more abstract and creative manner, developing thematic maps and conceptual continua that reflected relationships between and among participant responses. This process led to combining some themes and changing the title of other themes to better reflect the descriptive accounts of participants. Lastly, in refining the theme list, we discussed theme definitions and final theme names, attempting to capture the nature and essence of each thematic group (Braun & Clarke, 2006; Clarke & Braun, 2017). Clarke and Braun (2017) noted that “each theme has an ‘essence’ or core concept that underpins and unites the observations, much like characters have their own psychological makeup and motivations” (p. 108). In examining these underlying core concepts in our data, we identified questions that seemed to be illuminated through participants’ expressed concerns. As an additional step, we calculated frequency counts to convey the saturation of each theme within the data. Because the purpose of tallying frequencies was to report the strength of qualitative findings rather than to specifically quantify the results, greater weight was given to qualitative data than quantitative frequencies.


In reviewing the conceptual maps of participant responses, it appeared that participants varied in their degree of ethical concerns. To make meaning of this variation, the authors placed responses on a continuum from “none” to “yes.” These items were coded based upon whether an ethical concern was reported and under what conditions the ethical concerns existed. Some participants (4.2%, n = 13) entered “n/a,” but it could not be determined if these responses indicated whether they had any ethical concerns.

Continuum of Ethical Concerns

During the initial review of the data, the authors observed a response range that led to a further analysis of the continuum of responses. Most participants (78.2%, n = 244) indicated some level of ethical concern regarding the integration of neuroscience in counseling. These responses had various degrees of certainty and conditions. Most responses (65.1%, n = 203) fell into the yes, with no conditions grouping. Example responses included: “Deeply concerned” and “There’s a lot of misinformation out there! It’s a complex subject and I have seen varying degrees of ability to explain things easily and correctly. Also I think sometimes people want it to provide answers that it can’t or read more into the research than is truly there.”

The second category identified was yes, if/only (3.5%, n = 11). One example response included in this subtheme was: “I would only be concerned if counselors use their knowledge of the brain to profess some magical or intellectual superiority in controlling a client.” The third category was none, but (3.2%, n = 10). For example, responses included in this subtheme were: “none—except more research is needed,” and “none other than the importance of competence.”

The fourth category we identified was just like any other (3.2 %, n = 10). Some participants indicated that they had ethical concerns that were no different than for other methods of counseling. For example, one participant stated they felt “the same as with any other evidence-based practice: counselors need quality training and an understanding of what it means to be ‘competent.’” A fifth category was unethical not to integrate (3.2%, n = 10). An example response included in this subtheme was: “At this point, it would be unethical NOT to formally integrate these studies” (emphasis in original). Nearly 20% of participants (19.9%, n = 62) believed there were no ethical concerns regarding the integration of neuroscience in counseling. Given the methods of the study, the “n/a” responses were kept separate from the no ethical concerns group, as the analysis aimed to stick close to the participants’ actual words rather than infer their intention. Therefore, “n/a” could have been listed for any number of possible reasons that could not be determined in the current study. These responses were further divided into the following groups: (a) participants who believed there were explicitly no ethical concerns (13.8%, n = 43), (b) participants who believed there were no ethical concerns at the current moment (3.8%, n = 12), and (c) participants who believed there were no ethical concerns as long as certain conditions were met (2.2%, n = 7). This continuum provided a richer understanding of the emergent themes, as discussed below.

Themes of Participant Concerns

     Most participants (78.2%, n = 244) identified ethical concerns. From the continuum above, these are the responses from the following groups: unethical not to integrate; no ethical concerns but; ethical concerns if/only; ethical concerns with no conditions; and ethical concerns just like any other. The analysis of these responses produced a total of four themes and ten subthemes and are summarized in Table 1. The four major themes were: neuroscience does not align with our counselor identity, neuroscience is outside the scope of counseling practice, challenges with neuroscience and the nature of neuroscience research, and potential harm to clients. For each subtheme, response frequencies are reported to provide a contextual understanding of how commonly the theme occurred. Subthemes all were deemed equally meaningful, regardless of the response frequency.

Theme 1: Neuroscience Does Not Align With Our Counselor Identity

     The first theme was reflective of participants’ concerns that integrating neuroscience into counseling might be inherently inconsistent with or even violate counselors’ identity. Specifically, participants emphasized the loss of humanistic principles by either directly using the word “humanistic” or using terms consistent with humanistic principles (e.g., holism, human-first, subjective data, process, compassion, relationship, and wellness). Two subthemes related to the overarching theme were as follows: Subtheme 1.1) overemphasis and/or overreliance (n = 27), and Subtheme 1.2) reductionism and/or determinism (n = 25). These connected, yet discrete, subthemes reflected participants’ particular areas of apprehension. These areas of concern centered on either giving too much weight to biological, brain-based conceptualizations at the cost of clients’ subjective worlds (e.g., “undervalue subjective experience”) or reducing human experience in a way that neglected human agency (e.g., “reducing human experience to just science”).

Theme 2: Neuroscience Is Outside the Scope of Counseling Practice

The second theme was reflective of participants’ reservations that neuroscience was within counselors’ scope of practice based on educational backgrounds, training, knowledge, and/or skills. Three subthemes were identified as follows: Subtheme 2.1) training and education (n = 59), Subtheme 2.2) lack of standards for training and practice (n = 21), and Subtheme 2.3) competence (n = 69). Sample responses from this theme included feeling “woefully untrained.”  Some participants focused more on academic background and elements of training (e.g., continuing education, supervision) as indicative of scope, whereas other participants highlighted counselors’ understanding of neuroscience concepts, focusing more on knowledge and application skills. A smaller group of responses emphasized the absence of current training and/or practice standards (e.g., “inadequate training standards”). This line of responses included concerns around an absence of qualified trainers, certification opportunities, and/or general laws and regulations.

Theme 3: Challenges With Neuroscience and the Nature of Neuroscience Research

The third theme captured participants’ varied reservations about the general field of neuroscience and the accurate translation of neuroscience research into clinical work. Participants expressing concerns in this area seemed to be asking, “How can we be sure this is done right or well?”  Subtheme 3.1, ever-changing and evolving (n = 14), included responses related to challenges counselors might face in staying current with neuroscience findings. These concerns were centered around the vastness of the field and the fast pace at which research is emerging. Subtheme 3.2, quality of research (n = 23), included more critical commentary on the type of research being conducted in the neuroscience field (e.g., relevance of lab-based research to clinical practice, insufficient applied research). Subtheme 3.3, interpreting and applying research (n = 52), emphasized concerns with counselors overstating, speculating, misrepresenting, and misinforming clients of neuroscience research and concepts. Participants voiced concerns with “overhyping findings,” “unknown practical use,” and the “ever-changing and not fully understood” research base.

Theme 4: Potential for Harm to Clients

The fourth theme reflected participants’ concerns that integrating neuroscience into counseling could put clients, and potentially counselors, at risk. A total of 18 participants used the exact phrase “potential harm” or the related idea of informed consent. Fourteen participants referred to concerns with potential harm, and four people noted concerns with informed consent. In Subtheme 4.1, neuroscience information may be intentionally misused in a way that harms clients (n = 21), participants feared counselors deliberately using “embellishment” and “manipulation.” Subtheme 4.2, unintended potential negative side effects (n = 18), reflected ways that integration could inadvertently harm clients or harm counselors These concerns included giving false hope and creating problems with insurance claims to issues with liability and malpractice.


Table 1

Summary and Frequencies of Themes and Subthemes

Theme Subtheme Description Frequency Sample Statements
Theme One: Neuroscience does not align with our counselor identity Sub 1.1 Overemphasis and/or overreliance The integration of neuroscience in counseling may lead to counselors giving preference to non-humanistic aspects of the client and/or the treatment process (e.g., psychopharmacology, science, the brain). n = 27


• Too reliant on brain
• Science over compassion
• Defaulting to neuro
• Brain obsession
• Undervalue subjective
Sub 1.2 Reductionism and/or determinism The integration of neuroscience in counseling may lead to counselors moving away from holistic conceptualizations and limiting human agency.  


n = 25



• Oversimplification
• Takes away focus on
• Reducing human experience
to just science
• Cultural bias
Theme Two: Neuroscience is outside the scope of counseling practice Sub 2.1 Training and education Counselors do not have sufficient training and/or educational backgrounds to ethically integrate neuroscience into counseling practice.  

n = 59


• Insufficient training
• Woefully undertrained
• Not having qualifications
• Scope of training
• No formal supervision
Sub 2.2

Lack of standards for training and practice

There are insufficient standards for guiding the training and practice of neuroscience integration. n = 21 • Lack of laws, regulations, and
• Standards for qualifications
• Qualifications of trainers
Sub 2.3 Competence Counselors are integrating neuroscience into counseling practice without sufficient knowledge and/or skills. n = 69


• Lack of knowledge
• Scope of competence
• Not being informed
• Skill level of clinician
Theme Three: Challenges with neuroscience and the nature of neuroscience research Sub 3.1
Ever-changing and evolving
The field of neuroscience is continuously evolving, serving as a barrier to counselors staying sufficiently up to date to ethically integrate principles into counseling practice. n = 14


• Ever-changing and not totally
• Staying current
• Constantly evolving
• Keeping up to date
• Vastness of the field
Sub 3.2 Quality of research Neuroscience research is often too complex, poorly conducted, and/or insufficient for counselors to apply to their work. n = 23


• More research needed
• Poor research
• Generalizability of research
• Lack of scientific foundation
of knowledge
• Unknown practical use
Sub 3.3 Interpreting and applying research Neuroscience research is being misunderstood, misinterpreted, and/or inaccurately applied to clinical practice. n = 52


• Accurately interpreting and
• Overstatement
• Misrepresenting science
• Giving incorrect information
Theme Subtheme Description Frequency Sample Statements
Theme Four: Potential for harm to clients Sub 4.1 Manipulation Neuroscience information may be intentionally misused in a way that harms clients.  

n = 21


• Manipulation leading to
• Misuse of knowledge
• Controlling the client
Sub 4.2 Unintended potential negative side effects The integration of neuroscience into counseling may have unintended negative consequences on clients and/or counselors. n = 18


• Jargon alienates – feeling
• Clients misperceiving
counselor identity/role and
not attending other

Note. N = 312



Counselors, counselor educators, and counselors-in-training reported a wide range of ethical concerns regarding the integration of neuroscience with clinical practice. These concerns largely reflected existing ethical guidelines (ACA, 2014) and existing literature related to neuroscience and counseling (e.g., Beeson & Miller, 2019; Field, 2019; Luke, 2019; Wilkinson, 2018). We developed four primary themes through the data analysis process. In reviewing these themes, we identified questions that participants seem to be asking through their expressed concerns. Each of the themes shared a meaningful connection, through implication and association, with major sections of the ACA Code of Ethics (ACA, 2014). These connections are discussed below.

Theme 1: Neuroscience Does Not Align With Our Counselor Identity

Humanistic concerns in this theme reflect counselor concerns that the integration of neuroscience may shift the profession away from wellness and focus on pathology. As already noted, other scholars have shared this concern (Wilkinson, 2018). However, other authors have alluded to the possibility for neuroscience to expand rather than reduce the client experiences and actually enhance counselor identity (Beeson, Field, et al., 2019; Beeson & Miller, 2019; Field et al., 2019; Ivey & Daniels, 2016).

Humanistic concerns are consistent with criticisms in the literature regarding essentialism (Schultz, 2018). Essentialism, in particular Schultz’s neuroessentialism, is the process of reducing individuals down to mere brain function. This position reflects the positivist, materialist approach to science in general and neuroscience in particular. All human experience is based in neurobiological process (Kalat, 2019), which can feel deterministic and therefore diminish the hope that counselors are called to instill (Schwartz et al., 2016). This theme aligns with several ACA ethical codes, including counselor professional identity and values (Beeson & Miller, 2019). However, influential scholars in the counseling profession have elevated how neuroscience is an extension of the wellness perspective, akin to the professional identity of the counseling profession (Cashwell & Sweeney, 2016; Ivey et al., 2017; Russell-Chapin, 2016). Whereas this theme indicates that some counselors believe neuroscience poses ethical risks to professional identity, the reality remains unclear.

Theme Two: Neuroscience Is Outside the Scope of Counseling Practice

Concerns regarding the requisite knowledge or expertise of counselors aligns well with two specific ACA ethical code standards in this regard: C.2.a. Boundaries of Competence and C.2.b. New Specialty Areas of Practice. This theme assumes that there is a standard of competence that exists. In order for a counselor to be competent, there must be a standard to which they are compared. However, what qualifies a counselor to be competent integrating neuroscience is unclear. There are a few neuroscience-related standards outlined in the American Mental Health Counseling Association (AMHCA) Standards for the Practice of Clinical Mental Health Counseling (2020) pertinent to biological bases of behavior and CACREP practice standards (2015) pertinent to neurobiology. However, these standards are not widely known among counselors and lack recommendations for implementation (Beeson, Field, et al., 2019). This lack of explicit direction is similar to concerns regarding the implementation of other counseling standards, such as the Multicultural and Social Justice Counseling Competencies (Ratts et al., 2016).

Theme Three: Challenges With Neuroscience and the Nature of Neuroscience Research

The third theme highlighted the concern that understanding and applying the body of literature that undergirds integration are essential (Field et al., 2019; Luke, 2019). Neuroscience literature is ever-changing, ever-evolving. This rapid pace of change creates two challenges for counselors. First, counselors could have difficulty staying abreast of the state of the art of integration, leading to the potential for using outdated information in practice. Second, counselors might integrate early findings too quickly before there is enough evidence to support their integration. The quality of neuroscience-related research also appears to be a barrier to integration in that counselors may struggle to discern high-quality research from low-quality research (Gruber, 2017; Kim & Zalaquett, 2019). Related to this, counselors face the challenge of accurately interpreting and applying relevant research for practice. Results indicate a primary concern related to issues of accuracy, leading to misapplication, overstating implications, and misinforming clients. This concern is elevated by other research warning against presumed superiority in neuroscience research, given the potential for neuroscience to seduce, allure, and enchant consumers of literature (Coutinho et al., 2017; Lilienfeld, 2014; Weisberg et al., 2008). Concerns regarding the accuracy of neuroscience knowledge among counselors also have been cited (Kim & Zalaquett, 2019). However, counselors in at least one study indicated more accurate neuroscience knowledge and average endorsement of neuromyths when compared to educators, undergraduate students, and coaches (Beeson, Kim, et al., 2019).

These concerns align with several ACA ethical codes, including Section C: Professional Responsibility (2014). When counselors practice based on emergent literature with which they are only superficially familiar, they risk miscommunication with clients and damaging the veracity and integrity of the profession as it relates to client care. This finding is consistent with previous research (Bott et al., 2016; Luke, 2016) that highlights the risk of using information without great care.

Theme Four: Potential for Harm to Clients

The fourth theme has the highest salience for the profession, as safeguarding client safety and welfare are paramount (Kaplan et al., 2017). Results indicated that manipulation is a real concern among participants. Manipulation can occur through misuse, misrepresentation, embellishment, and controlling of clients through invoking neuroscience (Bott et al., 2016). Respondents reported that the actions leading to client harm may be overt. For example, in a desperate attempt to instill hope in a client, a counselor might overstate the concept of neuroplasticity. Similarly, in an effort to present as more competent than perhaps they feel, a counselor might use neuroscience-laden language with clients, resulting in alienation (Lebowitz et al., 2015). Harm may also occur through unintended consequences of integration. Clients may experience negative side effects such as false hope, deflected responsibility, and forgoing medical consultation. Similar concerns have been found in recent literature (Haslam & Kvaale, 2015; Lebowitz & Applebaum, 2017). These authors note that although on the surface integration seems positive, harm is possible. This underscores the purpose and importance of the ACA Code of Ethics regarding new specialty areas: “Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and protect others from possible harm” (ACA, 2014, C.2.b).


As with any qualitative data analysis, transferability is limited. The authors obtained the data from an online survey, using a convenience and snowball sampling method. Therefore, respondents may have had strong opinions regarding neuroscience and not necessarily be representative of the profession. Another limitation was the use of a single, open-ended question that did not allow for an in-depth follow-up. We made conservative inferences regarding the meaning and intent of the data in the discussion. However, interviews would have allowed for more context into participants’ answers. This has long been viewed as a threat to trustworthiness and transferability (Creswell & Plano-Clark, 2018). The structure of the survey in general and the question also could have influenced this result. For example, there was insufficient information available from the responses to know respondent motivation for “n/a” or “none” responses. Although it is likely that respondents did not feel they had enough information to identify ethical concerns, other reasons for such a response are also possible. White females also were overrepresented in the survey sample. This representation is consistent with surveys of CACREP-accredited graduate programs, in which White females are also overrepresented in student and faculty composition (CACREP, 2017). The findings from this study may have been different had the sample been more diverse. The voice of counselors-in-training may be overrepresented in the data. This may also reflect the increasing interest in new counselors-in-training and counselor educators–in–training of neuroscience-informed counseling (Beeson, Field, et al., 2019; Kim & Zalaquett, 2019).

Implications for Practice and Research

This research highlights the need for continued debate and evolution of who we are as counselors and what role neuroscience integration plays in our professional identity, training, and practice. Remaining silent runs the risk of counselors indiscriminately, and perhaps unethically, integrating neuroscience without adequate consideration to counselor professional identity (Luke, 2020). Forgoing these discussions also introduces the risk that counselors may not ensure that such integration enhances rather than detracts from our professional identity. Failing to do so would further support concerns described in 20/20: A Vision for the Future of Counseling (Kaplan & Gladding, 2011). The concerns highlight the consistent trend that best practices tend to be “dictated to counselors by other mental health professions” (p. 371).

A second implication is the need to clarify counselors’ scope of practice with regard to neuroscience. Only one comprehensive set of standards related to neuroscience currently exists (AMHCA, 2020). Yet even with these standards there is little awareness or training around application. Understanding scope will support preventing client harm by ensuring the previous themes are addressed. In this way, counselors will better understand the strengths and limitations of integrating neuroscience information with practice. Further, counselors should continue to practice humility regarding neuroscience evidence. In doing so, they will ensure that they also will be maintaining values (e.g., humanistic orientation) that are hallmarks of the counseling profession.

The results of this study highlight the need for more training in accessing, interpreting, and being current in neuroscience research. This focus includes the need to increase resources to support high-quality neuroscience-based studies in counseling. As scholars have asserted (e.g., Myers & Young, 2012), neuroscience provides a unique strategy to evaluate the outcomes of counseling services. The challenge, as we demonstrate in this article, is how the profession moves forward in view of these ethical standards. It is one thing to assert that counselors operate only within their scope of competence. It is another thing to articulate and circumscribe the limits of competence in an emergent area like neuroscience.

Determining ethical concerns regarding the integration of neuroscience in counseling requires several professional milestones to be met. This could begin with consensus building in the profession regarding neuroscience and counselor scope of practice. To accomplish this step, counselors need to define what it means to integrate neuroscience with practice. As noted in the current study, participants relied on their own operationalization of the integration of neuroscience. The resulting data seemed to indicate that most viewed this integration as neuroeducation (Miller, 2016) or technical applications (e.g., neurofeedback). Many have expressed more broad integration of neuroscience (e.g., Field et al., 2019) as a means to conceptualize client experiences and guide the selection and timing of various techniques.

Next, once integration is defined, there needs to be a clear standard for the training and practice of all master’s-level students (e.g., how much neuroscience does a master’s-level counselor need to know?). In addition, standards for advanced practice postgraduation also require consideration. It is unrealistic to think that master’s-level programs can prepare counselors to be experts in any area of practice, including neuroscience. As such, the profession also needs to define how much training is enough to ethically practice technology-based (e.g., neurofeedback) and non–technology-based (e.g., using to guide case conceptualization and treatment planning) integration. In doing so, counseling will create the scope of practice that can be used as a gauge of competence and limit risks to practicing outside of one’s scope.

Lastly, the counseling profession needs to develop an intentional research effort to validate training standards and therapeutic outcomes related to integration. Additional research is needed before we can appropriately discern future directions of integration. The current paucity of neuroscience literature in the counseling profession is concerning. Of particular concern is the lack of empirical and outcomes-based articles. The lack of training in how to design and evaluate research using emerging paradigms, such as the National Institutes of Health’s Research Domain Criteria, further isolates counselors from participating in national discourse regarding the future classification of mental functioning and mental health diagnoses. As the profession accomplishes these tasks, we will promote ethical care, limit the potential for harm, and ultimately advance the profession as a whole.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Chad Luke, PhD, NCC, MAC, ACS, LPC/MHSP, is an associate professor at Tennessee Tech University. Eric T. Beeson, PhD, NCC, ACS, LPC, CRC, is a core faculty member at The Family Institute at Northwestern University. Raissa Miller, PhD, LPC, is an assistant professor at Boise State University. Thomas A. Field, PhD, NCC, CCMHC, ACS, LPC, LMHC, is an assistant professor at the Boston University School of Medicine. Laura K. Jones, PhD, MS, is an assistant professor at the University of North Carolina at Asheville. Correspondence may be addressed to Chad Luke, Clinical Mental Health Counseling, Tennessee Tech University, P.O. Box 5031, Cookeville, TN 38505, cluke@tntech.edu.