Career Counselors Addressing Social Determinants of Mental Health in Rural Communities

Kaprea F. Johnson, Alexandra Gantt-Howrey, Bisola E. Duyile, Lauren B. Robins, Natese Dockery

Career counselors practicing in rural communities must understand and address social determinants of mental health (SDOMH). This conceptual article details the relationships between SDOMH domains and employment and provides evidence-based recommendations for integrating SDOMH into practice through a rural community health and well-being framework. Description of the adaptation of the framework for career counselors in rural communities, SDOMH assessment strategies and tools, and workflow adjustments are included. Conclusions suggest next steps for practice and research.

Keywords: social determinants of mental health, career counselors, rural communities, health and well-being framework, assessment

     Career counselors in rural communities address standard employment needs of the population, but they also must be aware of the socioeconomic circumstances that impact their community’s mental health and, in return, employment. Such socioeconomic factors are termed the social determinants of mental health (SDOMH). SDOMH are nonclinical psychosocial and socioeconomic circumstances that contribute to mental health outcomes (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). Healthy People 2030, a government initiative to promote health and well-being, describes a five-domain framework of SDOMH which includes: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context (ODPHP, n.d.). Collectively, SDOMH can disrupt overall well-being and have a cyclical relationship with employment. For example, in rural communities, minimal access to public transportation may make sustaining employment difficult, which can then impact health insurance. Without insurance, a person loses access to health care; with unmet health care needs, a person who is unwell and without access to treatment has less opportunity for employment. Thus, understanding and addressing SDOMH is critically important for career counselors working in rural and other underserved communities (Pope, 2011). This conceptual paper will define SDOMH, introduce a theoretical framework for addressing SDOMH, provide evidence-based recommendations for assessment and treatment, and conclude with national resources to support career counselors in rural communities as they incorporate addressing SDOMH into their work.

Rural Communities, Employment, and Career Counselors

The U.S. Census Bureau considers rural communities as a group of people, counties, and housing outside of an urban area. More specifically, the Office of Management and Budget defines rural as areas with an urban core population of fewer than 50,000 people (Health Resources and Services Administration, 2017). After the 2010 Census, it was estimated that approximately 15% of the population lives in rural communities (Health Resources & Services Administration, 2017). Rural communities experience higher rates of unemployment and poverty, and residents are therefore more likely to live below the poverty line (United States Department of Agriculture [USDA], 2014). This is largely rooted in the fact that rural communities experience underdevelopment, economic decline, and neglect (Dwyer & Sanchez, 2016). Economic focus in rural environments typically centers around agriculture, rather than technological advancement (Dwyer & Sanchez, 2016). This contributes in part to a dearth of economic resources and thereby to increased unemployment and poverty and reduced health and well-being outcomes (Bradshaw, 2007; Brassington, 2011; Dwyer & Sanchez, 2016).

According to research conducted by the USDA, the unemployment rate in rural communities steadily declined for approximately 10 years prior to the COVID-19 pandemic; in September of 2019, the rural unemployment rate was 3.5% (Dobis et al., 2021). However, unemployment in rural communities reached 13.6% in April 2020, with unemployment disparately affecting those in more impoverished communities (Dobis et al., 2021). The role and goal of the career counselor is to help individuals in a specific community obtain or retain employment (Landon et al., 2019). For example, career counselors start the counseling process by systematically assessing clients’ needs, qualifications, and job aspirations. They provide career planning services and effective job search strategies. They help with résumé writing, interview preparations, skill development, and training opportunities (Amundson, 1993). Further, career counselors provide case management services by tracking and monitoring their clients’ progress. They record client information, document counseling sessions, track job applications, and survey employment outcomes (Amundson, 1993). Through tailored support, the career counselor works with the client throughout the life span to support the search for and maintaining of employment, while building client resilience and feelings of empowerment along the way.

However, rural communities have limited employment options and self-employment opportunities, which makes the role of the career counselor difficult in rural settings. Individuals in rural communities seeking employment may find it difficult to trust an outside counselor, and they may experience limited or no access to mental health services, health care practitioners, and transportation services, thereby negatively impacting their ability to participate effectively in the employment process (Landon et al., 2019). Career counselors in rural settings must develop a broader range of skills and connections to better serve their clients. These inequities experienced in rural settings reflect SDOMH and are factors which interfere with the role of the career counselor.

Social Determinants of Mental Health and Employment
     SDOMH are the nonmedical factors shaped by the unequal distribution of power, privilege, and resources that influence the health outcomes of individuals and communities (World Health Organization, 2014). SDOMH concern the environmental living conditions that affect a wide range of health, functioning, and quality-of-life outcomes and risks (Centers for Disease Control and Prevention, 2020). In the Healthy People 2030 framework, the ODPHP (n.d.) defined social determinants of health (SDOH) through five primary domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context. These five domains are important to understand within the context of employment. In the Economic Stability domain, employment is the most pertinent issue (ODPHP, n.d.), as a lack of employment typically influences both mental and physical health (Norström et al., 2019). A few distinct factors related to economic stability and employment include job security, work environment, monetary factors (e.g., pay), and the demands of the job (ODPHP, n.d.). For example, in rural communities, agriculture is a significant source of employment for individuals. However, this source of income is seemingly unstable, as farming and agriculture are mostly dependent on the season (Liebman, 2010). In the Education Access and Quality domain, enrollment in higher education or holding a higher education degree has been found to have a positive impact on employment, as well as yielding more positive overall health outcomes and optimal well-being (ODPHP, n.d.; USDA, 2017). For adults living in rural communities, unemployment rates are higher for those with lower education attainment, further supporting the connection between education and employment (USDA, 2017). Regarding the Health Care Access and Quality domainspecifically in rural communitiesfactors such as proximity to hospitals, lack of insurance, and the overall cost of health care can reduce accessibility. Health care, especially higher-quality health care, aids in preventing disease and improving individuals’ quality of life (ODPHP, n.d.). However, inadequate health care leads to higher rates of disease, which have a direct impact on individuals’ ability to sustain employment, due to factors such as missing work because of illness or having to travel further to receive health care (Dueñas et al., 2016).

Ability to travel is also a cause for concern in rural communities and is closely related to the Neighborhood and Built Environment domain. Healthy People 2030 proposed various objectives related to neighborhood and built environment, with one being to increase access to mass transit (ODPHP, n.d.). It is apparent that a lack of reliable transportation is directly tied to unemployment, especially in rural communities due to distance and limited accessibility (U.S. Department of Transportation, 2019). Public transportation carries many noteworthy benefits, such as reducing air pollution, being inexpensive compared to purchasing a car, minimizing the cost of fuel and upkeep for personal vehicles, and increased convenience. Although these positive aspects of public transportation are ideal, individuals living in rural communities may not be able to reap these benefits due to the lack of public transportation in these areas, perhaps also limiting employment options (Shoup & Homa, 2010; U.S. Department of Transportation, 2019).

Lastly, the fifth domain, Social and Community Context, is interrelated with employment, as it tends to have a significant impact on workplace conditions, influences individuals’ overall mental and physical health, and can hinder growth and development (Norström et al., 2019). Additionally, social cohesion and adequate support in communities can be leveraged to locate and obtain employment and other helpful resources; however, this often falls short in rural communities. For example, in rural communities, the inability to secure gainful employment is notably linked to geographical disparities, such as those within the Neighborhood and Built Environment SDOH domain. Examples of such geographic disparities which affect employment include limited or nonexistent options for public transportation, a lack of available local jobs, and a lack of childcare facilities for use by working parents. Rural communities also often experience a lack of resources to improve the employment outlook and overall well-being of their population (Bradshaw, 2007; Dwyer & Sanchez, 2016). In addition, structurally, it has been observed that economic resources tend to cluster or aggregate together. For example, businesses that have been successful in a community invite and attract more businesses, thus pulling resources away from rural communities that might not have such a history of business success. Meanwhile, communities that are left behind experience economic restructuring and delays in receiving new technologies, leading to fewer employment opportunities (Bradshaw, 2007; Landon et al., 2019). Thus, providing employment or vocational services in rural America can be particularly challenging.

Furthermore, unemployment, poverty, and mental health concerns are inextricably linked. When career counselors uncover and address these factors in rural America, they must consider the surplus of needed services and resources to systemically address interrelated issues. To be intentional, career counselors practicing in rural communities should consider using a theoretical foundation that provides direction for action on the SDOMH which impact their clients’ lives and ability to be gainfully employed. The Rural Community Health and Well-Being Framework (Annis et al., 2004) is a framework that would be exceedingly helpful in this pursuit.

Theoretical Framework for Action: Rural Community Health and Well-Being Framework

Rural communities make up over 20% of the population and are often classified by a lack of necessary resources, lower levels of education, and persistent economic inequities (Hughes et al., 2019; Mohatt et al., 2006). Although they face many challenges, individuals in rural communities have been found to be resilient, especially when the proper resources are available (Annis et al., 2004). Application of a theoretical framework to practice centered on the unique needs of rural communities is important in addressing SDOMH through career counseling. The Rural Community Health and Well-Being Framework (Annis et al., 2004) strategically builds upon community resiliency and identifies economic, social, and environmental factors which are seen as essential components of health in rural communities. This framework also implores career counselors to consider how SDOMH indicators impact the community as a whole as well as individual people. For example, the framework provides specific areas for increased career counselor awareness and action: health, safety and security, economics, education, environment, community infrastructure and processes, recreation, social support and cohesion, and the overall population. These specific areas for rural communities are within the SDOMH domains, but emphasis is placed on recognition of the specific areas within the SDOMH domains that have the greatest impact on the community.

This comprehensive framework centers the needs of rural communities and provides direction for assessing and addressing SDOMH that impact employment and overall well-being. This framework will assist in uncovering employment issues and barriers faced by individuals within rural communities. Using this framework to assess SDOMH conditions (e.g., economic, social, environmental) will aid in developing employment and mental health interventions that are socially conscious and address root causes of unemployment and poor mental health. Overall, this framework provides a model for assessing and addressing SDOMH in rural communities.

Adaptation for Career Counselors
     Career counselors in rural communities who wish to use the Rural Community Health and Well-Being Framework for practice should consider doing the following: (a) increasing their awareness and understanding of SDOMH and the framework, (b) increasing their understanding of the specific community needs outlined by the framework, and (c) assessing the values and needs of the community. However, because the framework is primarily focused on community-level indicators of need, career counselors will need to adapt what they learn about the community to inform their practice with individual community members. The role of the career counselor is multifaceted; thus, career counselors can engage various aspects of their role, such as listener, leader, and evaluator, in their advocacy efforts.

To begin this process of learning about community and individual needs, Annis et al. (2004) suggested the importance of listening. For example, based on the community-level indicators of need, career counselors can assess individual clients for their unmet needs within those specific areas. By understanding how members of the community are experiencing indicators such as health, recreation, social support, transportation, and resources, career counselors will become better equipped to understand and address issues that are impacting their clients’ ability to obtain and maintain employment. Beyond the use of assessments, this framework equips career counselors to broach important conversations about social needs (Andermann, 2016) with their clients, to inform potential connection with community resources. These conversations may include explicit discussion about particular SDOMH challenges (e.g., education, safety, access to affordable childcare), as well as about the client’s sense of belonging, or lack thereof, within their community. These conversations should allow for increased understanding and rapport building through genuine listening and empathy (Annis et al., 2004; Covey, 1989).

Finally, the framework implores career counselors to advocate with and for individuals within their rural community to provide equitable employment opportunities (Crumb et al., 2019). Such advocacy may take place through connection with local rural community leaders, who may have power to alter or increase the distribution of certain resources within the community setting. For example, a career counselor may advocate on behalf of their clients to the local county board of commissioners for increased budget toward affordable transportation access within that county, thereby broadening clients’ access to job opportunities. Advocacy with local leaders outside of government might include collaboration with community college administrators for provision of additional support for working adults and parents who wish to return to school, such as more evening course options, advisor support, or readily available information on scholarships. Again, considering the aforementioned roles career counselors may have (e.g., leader, evaluator), career counselors may also consider further training in program evaluation—or collaboration with those who have such training—to better understand the efficacy of their community partnerships, referrals, and other advocacy-related efforts made toward supporting clients’ SDOMH.

Assessing and Addressing Social Determinants of Mental Health
     As noted earlier, SDOMH are inextricably linked to employment, which means career counselors in rural communities must acknowledge these challenges and seek to address these issues with their clients. However, researchers have also highlighted the importance of considering both facilitators and barriers to addressing SDOMH challenges (Browne et al., 2021). In a qualitative case study of staff at a community health center and hospital, participants identified practical facilitators of SDOMH response, including community collaboration and support from leadership, as well as barriers such as time limitations and lack of resources (Browne et al., 2021). As career counselors hold similar client outcome goals as community mental health providers, they can take these findings into consideration when determining how to best respond to clients’ SDOMH challenges through attention to opportunities for collaboration with community leaders (e.g., religious leaders, politicians) and resources within the community (e.g., food banks, health care providers). Another study highlighted the importance of collaboration, partnerships with local agencies, and understanding the role of the counselor in SDOMH response (Johnson & Brookover, 2021; Robins et al., 2022). With these findings in mind, career counselors in rural communities are well positioned to assess for and address SDOMH challenges faced by their clients (Crucil & Amundson, 2017; Tang et al., 2021) through individual-level action (i.e., counseling) and systems-level advocacy action.

Systems-Level Advocacy Through Assessment
     To effectively engage in systems-level advocacy, it is important for career counselors to recognize and understand the needs of their rural communities. When using the Rural Community Health and Well-Being Framework in practice, it is important to complete an assessment of the rural health of one’s community. Ryan-Nicholls and Racher (2004) purport that it is imperative to assess rural health within five categories: health status, health determinants, health behavior, health resources, and health service utilization. Counselors may consider these items when assessing the needs of their clients in rural communities, as these items provide a basis for assessment of other health factors, such as indicators of community health (e.g., environment and lifestyle) and economic well-being, and provide a foundation for systems-level advocacy and planning. This level of action focuses on improving the lives of the entire community through strategic advocacy efforts that improve population health and well-being (Ryan-Nicholls & Racher, 2004). A career counselor engaged at this level might focus their energy on advocating for increased economic development in their rural community, livable wages, universal health care, immigration issues, employment discrimination legislation, and other employment-related issues that impact the community directly or indirectly. Additionally, a career counselor may address client self-advocacy and utilize empowerment approaches to increase the voices of community members and their clients as related to work and employment needs.

In connection with this framework (Annis et al., 2004), career counselors can utilize this broader community-level assessment to inform specific points of advocacy. As an example, Annis et al. (2004) provided a sample form that may be utilized to collect community data on alcohol consumption (p. 79). Upon noting concern from individual clients on alcohol consumption, a career counselor may collaborate with public health professionals, for instance, to collect such data from the local community. Annis et al. encourage consideration of the implications for such findings, as well as opportunities for follow-up. After determining a need in the community for support regarding high alcohol consumption, the career counselor may utilize the framework to consider points of community resilience, including existing supports, attitudes about alcohol consumption, existing resources, and any actions the community is already taking in this area. Overall, assessment through the context suggested by Ryan-Nicholls and Racher (2004) may yield individual and community data to inform action to address SDOMH challenges through Annis et al.’s (2004) framework.

Individual-Level Action Through Assessment
     When a client seeks services from a career counselor, the relationship centers on exploration and evaluation of the client’s education, training, work history, interests, skills, personality, and career goals. Through engaging with the Rural Community Health and Well-Being Framework, the career counselor might also examine the SDOMH facilitators and barriers that impact a client’s employment goals. To address employment and SDOMH, a career counselor must understand the community-level needs (i.e., systems approach) and the individual needs of their clients; for these goals, one strategy is to use assessments. There are various assessment tools that career counselors may find helpful, including the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE; National Association of Community Health Centers, 2017), an SDOH assessment tool purposed to empower professionals to not only understand their clients more holistically through assessment, but to better meet clients’ needs through the use of such information. The PRAPARE assessment tool includes questions related to four domains: Personal Characteristics, Family and Home, Money and Resources, and Social and Emotional Health. PRAPARE emphasizes the importance of assessing SDOMH needs of clients in order for providers to “define and document the complexity of their patients; transform care with integrated services and community partnerships to meet the needs of their patients; demonstrate the value they bring to patients, communities, and payers; and advocate for change in their communities” ( There are several benefits of using the PRAPARE assessment tool, such as it being free of charge, having a website linked to the tool with an “actionable toolkit and resources,’’ and being evidence-based. Barriers to using PRAPARE include that it is a long assessment tool that clients must complete in-office, which may slow workflow.

Another SDOH assessment tool is the WellRx Questionnaire (Page-Reeves et al., 2016). The WellRx Questionnaire is an 11-item screening tool that gathers information on various SDOMH, like food security, access to transportation, employment, and education. Participants are to answer “yes” or “no” to each item on the questionnaire. According to Page-Reeves and colleagues (2016), the WellRx Questionnaire provides a feasible means of assessing patients’ social needs and thereby addressing those needs. Benefits to using the WellRx include that it is free of cost, questions are at a 4th-grade reading level, and it can typically be completed by a client individually without the help of a professional. A potential barrier is that it does not assess a wide range of SDOMH challenges. Lastly, Andermann (2018) conducted a scoping review of social needs screening tools and found that the focus on such screening has increased over time. Andermann suggested that health care workers take advantage of the existing means of assessment, and made a number of specific resource recommendations, such as the Canadian Task Force on Preventive Health Care (2019) and the U.S. Preventive Services Task Force (2022).

Addressing SDOMH Through Action
     Documenting and defining the needs of clients through assessment is the first step in addressing SDOMH. The next step is taking action through an integrated career counseling approach. An integrated approach may include consistent collaboration with other professionals, like medical doctors, nurse practitioners, social workers, probation officers, or case managers. Additionally, scholars like Andermann (2016) suggest integrated efforts such as ensuring social challenges are included in client records and shared with other professionals to best support care. For “particularly isolated and hard-to-reach patients . . . [actions like] assertive outreach, patient tracking and individual case managers” may be helpful (para. 19). Another practical suggestion for beginning to address clients’ SDOMH challenges is adding an SDOMH assessment tool or specific SDOMH questions to an intake form that the client completes independently or during the intake session. Selection of specific questions can be derived from the data that displays community-level needs (e.g., systems-level advocacy through assessment). For example, if a community-level assessment found that public transportation was lacking, then transportation might be an important assessment question on the SDOMH screener.

Another consideration specific for career counselors is that counselors are obligated by their code of ethics to take appropriate action based on assessment results (American Counseling Association [ACA], 2014, Section E.2.b.). Appropriate action can include consultation and collaboration with other professionals within and outside of counseling and/or advocacy to address the SDOMH need. After establishing the need through assessment, it is important for the career counselor to support the client in understanding system-level challenges and to work to address SDOMH issues while simultaneously supporting employment needs. For example, a career counselor who determines that their client is struggling with food insecurity might address this issue in several ways. At the individual level, the counselor might print resources for local food pantries, assist the client in applying for SNAP benefits, and counsel the client on resources within the community to access food. They could establish a small food pantry within the office, collaborate with local restaurants to receive pre-packaged food that might otherwise be disposed of, or consult with local food pantries and free food kitchens to establish a mobile pantry and kitchen. At the systems level, a career counselor may build partnerships with local farmers to increase locations where fresh fruits and vegetables are available for little or no cost.

Collaboration and consultation are imperative to addressing the complex needs of clients in rural communities who are both seeking career counseling and challenged by SDOMH issues. For example, as noted earlier, health care access and quality are major disruptors of employment, and addressing these challenges will afford benefits for employment. The career counselor can consider using interprofessional collaboration and telehealth to support the health care needs of their rural clients (Johnson & Mahan, 2020). Interprofessional collaboration is a practice in which health care providers from two or more professional backgrounds interact and practice with the client at the center of care (Prentice et al., 2015). Using telehealth, the distribution of health-related services via telecommunication technologies is a useful strategy to support the health care needs of persons in rural communities. A career counselor can address health care access through telehealth in several ways, including education (e.g., introduce their client to telehealth; assist them in understanding the technology), telehealth (e.g., provide the telecommunication equipment in the office), and collaborative partnership (e.g., use a portion of the career counseling session to assist the client in connecting with health care providers using distance technology). As a collaborative partner in addressing health care access and quality, the career counselor can also use future sessions to follow up with the client on their experience with telehealth and, if needed, assist them in connecting to other health care providers. Figure 1 provides a visual for conceptualizing how career counselors may navigate the SDOMH needs of their clients, from assessment to action.

Figure 1
Working to Address Clients’ SDOMH Needs

Lastly, in the work of addressing SDOMH and employment, counselors should be aware of local, state, and national resources. Local and state resources are unique to every state but have similar purposes which include disseminating information on local resources and initiatives and providing public services that address SDOMH (e.g., food banks, public programs). National resources that are accessible to every community include 211 and the “” website. The Federal Communications Commission designated 211 as a national number in the United States that anyone can call for information and referrals to social services and other assistance. The services provided by 211 are confidential and free, available 24/7, and help connect people in the United States to essential community services. Moreover, the “” website is designed to help people search and connect with social care support based on their ZIP Code.

Integrating career counseling and social care support in rural communities is a strategy to facilitate the readiness of clients for work and the sustainability of employment for clients because basic needs are met or being addressed. While every rural community is unique, the foundation of understanding both systemic and individual SDOMH needs—and addressing those needs through strategic partnerships and individual counseling, as well as advocacy—is important in every rural community and to the success of any career counseling endeavor.


In rural communities, career counselors hold a significant role. They are tasked with aiding individuals with employment needs; they may often address mental health concerns, and while doing so, it is important for them to be aware of and prepared to address SDOMH. Career counselors can gain more insight into issues related to SDOMH through consultation, collaboration, and advocacy, which should all be a part of the repertoire of a rural career counselor. The use of theoretical frameworks such as the Rural Community Health and Well-Being Framework (Racher et al., 2004) provides direction for career counselors seeking to understand the systemic issues impacting employment access and opportunities in the community, as well as direction for intervention. This framework will assist in identifying and minimizing barriers to employment that may exist within rural communities. More specifically, this framework will help to uncover SDOMH challenges that exist in the community and serve as barriers to well-being and employment and provide direction for advocating for resources necessary for equitable work opportunities and environments. Being that individuals in rural America experience various barriers that have huge impacts on their lives, such a guide for career counselors is essential.

Lastly, addressing SDOMH within career counseling is a social justice issue that counselors should address (ACA, 2014; Crucil & Amundson, 2017; Ratts et al., 2016). The Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016) serve as a guide for counselors to address social justice issues and were endorsed by the ACA in 2015. Like the aforementioned framework and empirically based suggestions, the MSJCC includes four areas of competence: counselor self-awareness, client worldview, counseling relationship, and counseling and advocacy interventions. The authors of the MSJCC also implore counselors to consider “attitudes and beliefs, knowledge, skills, and action,” and suggest that competent counselors are aware of the experiences of marginalized clients (Ratts et al., 2016; p. 3). Thus, career counselors’ efforts to assess and address the individual and systems-based SDOMH challenges faced by their clients is social justice work that career counselors are trained and prepared to address.


Given this review, there are specific implications for career counselors practicing in rural communities, counselor educators training career counselors, and pertinent policy needs.

Practicing Career Counselors
     The role of the career counselor often entails identifying employment objectives, goals, and needs for both the job seeker and employer. In addition, the career counselor is responsible for résumé development, teaching job placement and retention skills, providing self-advocacy tips, teaching organizational goal–redefining skills, and many other components (Ysasi et al., 2018). However, providing these services can be difficult when the individuals reside in rural communities because of the SDOMH disparities such as limited available resources, isolation, increased poverty, and decreased educational and employment opportunities (Temkin, 1996).

Therefore, career counselors must actively work to ensure their visibility and accessibility to individuals in rural areas who are seeking employment opportunities. Further, career counselors need to market themselves and their skills to employers and job seekers of rural communities. Consequently, marketing generally entails engaging and developing community partnerships with employers and job seekers, which involves educating individuals unfamiliar with the specific services that career counselors provide. In addition, employers are often interested in services that improve their business (e.g., increase revenue), while job seekers may be searching for skill training to achieve employment goals (Richardson et al., 2010). Therefore, career counselors can enhance service delivery and provide adequate services when they intentionally market their services to the community members.

Furthermore, job insecurity has been linked to mental health concerns like stress and anxiety, financial concerns, and fear of organizational change (Holm & Hovland, 1999). Therefore, career counselors need to be aware of the impact of job insecurity on rural communities and devise strategies to help organizations and workers manage job insecurity. Managing job insecurity of workers in rural organizations could include helping organizations to redefine their present and future goals and commitments made to employees. Organizations could also manage organizational transitions depending on the skills and resources available to affected employees (Holm & Hovland, 1999). Clearly stated organizational objectives, goals, and plans can help employees feel less insecure about their jobs and increase focus on their roles and responsibilities instead of devising means to move out of the community for a better and more secure future. In addition, career counselors in rural communities should be aware of the mental health concerns experienced by employees and job seekers and connect them to available mental health resources.

Counselor Educators
     Counselor educators are responsible for the training and development of the next generation of counselors, including career counselors. It will be important for counselor educators to include training on SDOMH, interprofessional collaboration, and telehealth, as these are especially relevant for rural communities ( Johnson & Mahan, 2021; Johnson & Rehfuss, 2021). It is essential to provide adequate time to review and discuss SDOMH in all courses throughout the curriculum (Waters et al., 2022) to ensure the competence of career counselors. To ensure this continuity, counselor educators should advocate for an SDOMH module across the curriculum. This would ensure the inclusion of this content throughout the program, providing ample opportunity for the understanding of SDOMH and how they should be addressed. Career counselors must be prepared to address the complex employment and social health needs with which their clients might present. Without adequate education and training, these will seem much more difficult to address.

     In addressing both SDOMH and employment needs in rural communities, advocating for policy and legislative change is imperative. Lewis et al. (2002) described counselors’ roles in sharing public information as awakening the public to macro-systemic issues related to human dignity and engaging in social/political advocacy, or “influencing public policy in a large, public arena” (p. 2). Thus, career counselors are encouraged to benefit their clients through engaging in advocacy to influence policy at the local, state, and national levels. Similarly, Crucil and Amundson (2017) implore career counselors to engage in the work of influencing politics and policy and suggest awareness as a first step to enacting change through the sharing of information and impacting policy. To develop such awareness, career counselors may begin by reading about SDOMH disparities related specifically to employment issues from reputable sources. For instance, the National Alliance on Mental Illness (NAMI; 2014) has published various reports related to such issues, including the informative publication entitled Road to Recovery: Employment and Mental Illness. NAMI (2021) also published a legislative coalition letter written in support of increased SDOH funding to Congress. Career counselors may work to build their own awareness and understanding of the social and political events and influences which impact their clients, building toward eventual action in this realm.

Moreover, regarding policy change, researchers have suggested career counselors should be aware of and actively engaged in policy efforts (Crucil & Amundson, 2017; Watts, 2000). Watts (2000) described public policy considering career development as including four distinct roles: legislation, remuneration, exhortation, and regulation. Watts described these roles in detail and implored career counselors to influence these policy processes by seeking the support of interest groups and communicating with policy makers. Again, career counselors can work individually and within their own communities to increase their awareness and knowledge of policies and their impact. They can work toward influencing policies at the state and national levels to improve the accessibility and existence of important social programs and resources.


Career counselors in rural communities have a responsibility to acknowledge and address SDOMH challenges that are disproportionately impacting their clients. Collaboration, consultation, counseling framed through the lens of SDOMH, and advocacy appear to be strategies to support the employment needs of individuals and the rural community. Employment services in rural communities must be framed through a socially conscious (e.g., aware of the SDOMH systemic issues), action-oriented (e.g., prepared to engage in advocacy), and resiliency-focused lens that provides tailored individual services while simultaneously addressing systemic issues.

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


American Counseling Association. (2014). ACA code of ethics.

Amundson, N. E. (1993). Mattering: A foundation for employment counseling and training. Journal of Employment Counseling, 30(4), 146–152.

Andermann, A. (2016). Taking action on the social determinants of health in clinical practice: A framework for health professionals. Canadian Medical Association Journal, 188(17–18), E474–E483.

Andermann, A. (2018). Screening for social determinants of health in clinical care: Moving from the margins to the mainstream. Public Health Reviews, 39(1), 1–17.

Annis, R. C., Racher, F., & Beattie, M. (Eds.). (2004). Rural community health and well-being: A guide to action. Rural Development Institute.

Bradshaw, T. K. (2007). Theories of poverty and anti-poverty programs in community development. Community Development38(1), 7–25.

Brassington, I. (2011). What’s wrong with the brain drain? Developing World Bioethics, 12(3), 113–120.

Browne, J., Mccurley, J. L., Fung, V., Levy, D. E., Clark, C. R., & Thorndike, A. N. (2021). Addressing social determinants of health identified by systematic screening in a Medicaid accountable care organization: A qualitative study. Journal of Primary Care & Community Health, 12.

Canadian Task Force on Preventative Health Care. (2019). Canadian task force on preventive health care.

Centers for Disease Control and Prevention. (2020). CDC 2020 in review.

Covey, S. (1989). The 7 habits of highly effective people: Restoring the character ethic. Simon & Schuster.

Crucil, C., & Amundson, N. (2017). Throwing a wrench in the work(s): Using multicultural and social justice competency to develop a social justice–oriented employment counseling toolbox. Journal of Employment Counseling, 54(1), 2–11.

Crumb, L., Haskins, N., & Brown, S. (2019). Integrating social justice advocacy into mental health counseling in rural, impoverished American communities. The Professional Counselor, 9(1), 20–34.

Dobis, E. A., Krumel, T. P., Jr., Cromartie, J., Conley, K. L., Sanders, A., & Ortiz, R. (2021). Rural America at a glance: 2021 edition. U.S. Department of Agriculture.

Dueñas, M., Ojeda, B., Salazar, A., Mico, J. A., & Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research, 2016(9), 457–467.

Dwyer, R. E., & Sanchez, D. (2016). Population distribution and poverty. In M. J. White (Ed.), International handbook of migration and population distribution (pp. 485–504). Springer Science & Business Media.

Health Resources and Services Administration. (2017). Defining rural population.

Holm, S., & Hovland, J. (1999). Waiting for the other shoe to drop: Help for the job-insecure employee. Journal of Employment Counseling, 36(4), 156–166.

Hughes, M. C., Gorman, J. M., Ren, Y., Khalid, S., & Clayton, C. (2019). Increasing access to rural mental health care using hybrid care that includes telepsychiatry. Journal of Rural Mental Health, 43(1), 30–37.

Johnson, K. F., & Brookover, D. L. (2021). School counselors’ knowledge, actions, and recommendations for addressing social determinants of health with students, families, and in communities. Professional School Counseling, 25(1), 1–12.

Johnson, K. F., & Mahan, L. B. (2020). Interprofessional collaboration and telehealth: Useful strategies for family counselors in rural and underserved areas. The Family Journal, 28(3), 215–224.

Johnson, K. F., & Rehfuss, M. (2021). Telehealth interprofessional education: Benefits, desires, and concerns of counselor trainees. Journal of Creativity in Mental Health, 16(1), 15–30.

Johnson, K. F., & Robins, L. B. (2021). Counselor educators’ experiences and techniques teaching about social-health inequities. Journal of Counselor Preparation and Supervision, 14(4), 1–25.

Landon, T., Connor, A., McKnight-Lizotte, M., & Peña, J. (2019). Rehabilitation counseling in rural settings: A phenomenological study on barriers and supports. Journal of Rehabilitation, 85(2), 47–57.

Lewis, J., Arnold, M. S., House, R., & Toporek, R. L. (2002). ACA advocacy competencies.

Liebman, A. K., & Augustave, W. (2010). Agricultural health and safety: Incorporating the worker perspective. Journal of Agromedicine, 15(3), 192–199.

Mohatt, D. F., Bradley, M. M., Adams, S. J., & Morris, C. D. (2006). Mental health and rural America: 1994-2005. An overview and annotated bibliography. U.S. Department of Health and Human Services.

National Alliance on Mental Health. (2014). Road to recovery: Employment and mental illness.

National Alliance on Mental Health. (2021, April 8). Letter to congressional leadership.

National Association of Community Health Centers. (2017). PRAPARE.

Norström, F., Waenerlund, A.-K., Lindholm, L., Nygren, R., Sahlén, K.-G., & Brydsten, A. (2019). Does unemployment contribute to poorer health-related quality of life among Swedish adults? BMC Public Health, 19(1).

Office of Disease Prevention and Health Promotion. (2020). Healthy People 2030: Social determinants of health. U.S. Department of Health and Human Services.

Page-Reeves, J., Kaufman, W., Bleecker, M., Norris, J., McCalmont, K., Ianakieva, V., Ianakieva, D. & Kaufman, A. (2016). Addressing social determinants of health in a clinic setting: The WellRx pilot in Albuquerque, New Mexico. The Journal of the American Board of Family Medicine, 29(3), 414–418.

Pope, M. (2011). The Career Counseling With Underserved Populations model. Journal of Employment Counseling, 48(4), 153–155.

Prentice, D., Engel, J., Taplay, K., & Stobbe, K. (2015). Interprofessional collaboration: The experience of nursing and medical students’ interprofessional education. Global Qualitative Nursing Research2, 1–9.

Racher, F., Everitt, J., Annis, R., Gfellner, B., Ryan-Nicholls, K., Beattie, M., Gibson, R., & Funk, E. (2004). Rural community health & well-being. In R. Annis, F. Racher, & M. Beattie (Eds.), Rural community health and well-being: A guide to action (pp. 18–37). Rural Development Institute.

Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48.

Richardson, N., Gosnay, R. M., & Carroll, A. (2010). A quick start guide to social media marketing: High impact low-cost marketing that works. Kogan Page Publishers.

Robins, L. B., Johnson, K. F., Duyile, B., Gantt-Howrey, A., Dockery, N., Robins, S., & Wheeler, N. (2022). Family counselors addressing social determinants of mental health in underserved communities. The Family Journal, 31(2), 213–221.

Ryan-Nicholls, K. D., & Racher, F. E. (2004). Investigating the health of rural communities: Toward framework development. Rural and Remote Health, 4(1), 1–10.

Shoup, L., & Homa, B. (2010). Principles for improving transportation options in rural and small town communities.

Tang, M., Montgomery, M. L. T., Collins, B., and Jenkins, K. (2021). Integrating career and mental health counseling: Necessity and strategies. Journal of Employment Counseling, 58, 23–35.

Temkin, A. (1996). Creative options for rural employment: A beginning. In N. L. Arnold (Ed.), Self-employment in vocational rehabilitation: Building on lessons from rural America (pp. 61–64). Research and Training Center on Rural Rehabilitation Services.

United States Census Bureau. (2014). 2010-2014 ACS 5-year estimates.

United States Department of Agriculture. (2014). Rural America at a glance: 2014 edition.

United States Department of Agriculture. (2017). Rural education at a glance, 2017 edition.

United States Preventive Services Taskforce. (2022). US preventative services taskforce.

U.S. Department of Transportation. (2019). Rural public transportation systems.

Waters, J. M., Gantt, A., Worth, A., Duyile, B., Johnson, K. F., & Mariotto, D. (2022). Motivated but challenged: Counselor educators’ experiences teaching about social determinants of health. Journal of Counselor Preparation and Supervision, 15(2), 1–30.

Watts, A. G. (2000). Career development and public policy. Journal of Employment Counseling, 37(2), 62–75.

World Health Organization. (2014). Social determinants of mental health.

Ysasi, N. A., Tiro, L., Sprong, M. E., & Kim, B. J. (2018). Marketing vocational rehabilitation services in rural communities. In D. A. Harley, N. A. Ysasi, M. L. Bishop, & A. R. Fleming (Eds.), Disability and vocational rehabilitation in rural settings: Challenges to service delivery (pp. 545–552). Springer.

Kaprea F. Johnson, PhD, LPC, is a professor and Associate Vice Provost for Faculty Development & Recognition at The Ohio State University. Alexandra Gantt-Howrey, PhD, LPC (ID), is an assistant professor at Idaho State University. Bisola E. Duyile, PhD, LPC, CRC, is an assistant professor at Montclair State University. Lauren B. Robins, PhD, is a clinical assistant professor and distance learning coordinator at Old Dominion University. Natese Dockery, MS, NCC, LPC, CSAM, is a licensed professional counselor and doctoral student. Correspondence may be addressed to Kaprea F. Johnson, The Ohio State University, 1945 N. High Street, Columbus, OH 43210,

The More, the Merrier? A Phenomenological Investigation of Counselor-in-Training Simultaneous Supervision

William B. Lane, Jr., Timothy J. Hakenewerth, Camille D. Frank, Tessa B. Davis-Price, David M. Kleist, Steven J. Moody


Interpretative phenomenological analysis was used to explore the simultaneous supervision experiences of counselors-in-training. Simultaneous supervision is when a supervisee receives clinical supervision from multiple supervisors. Sometimes this supervision includes a university supervisor and a site supervisor. Other times this supervision occurs when a student has multiple sites in one semester and receives supervision at each site. Counselors-in-training described their experiences with simultaneous supervision during the course of their education. Four superordinate themes emerged: making sense of multiple perspectives, orchestrating the process, supervisory relationship dynamics, and personal dispositions and characteristics. Results indicated that counselors-in-training experienced compounded benefits and challenges. Implications for supervisors, supervisees, and counselor education programs are provided.

Keywords: clinical supervision, simultaneous supervision, counselors-in-training, interpretative phenomenological analysis, counselor education

     Supervision is a key component of counselor education in programs accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP; 2015) and an ethical requirement in the ACA Code of Ethics (American Counseling Association, 2014). Supervision of counselors-in-training (CITs) serves the purpose of guiding counselor development, gatekeeping, and, ultimately, ensuring competent client care (Borders et al., 2014). For the present study, we defined simultaneous supervision as a pre-licensure CIT receiving weekly individual or triadic supervision from more than one supervisor over the same time period. At the time of the study, the 2016 CACREP standards required that internship and practicum students receive individual and/or triadic supervision averaging 1 hour per week throughout their clinical experience (Standards 3.L. & 3.H.). Some CITs may gain field experience at multiple clinical sites requiring individual site supervision at each site. Many programs require students to engage in faculty advising meetings (Choate & Granello, 2006), which may take a form analogous to formal supervision. Additionally, supervisees may have clinical supervision, focused on supervisee development and client welfare, as well as administrative supervision, focused on functionality and logistics within an agency; these roles may be fulfilled by the same person or at times by two separate supervisors (Kreider, 2014; Tromski-Klingshirn & Davis, 2007). Consequently, although simultaneous supervision is not required in and of itself, it often occurs in counselor education practice.

Supervision Foundations
     Counseling supervision research has increased significantly in the last few decades (Borders et al., 2014). Borders and colleagues (2014) developed best practices for effective supervision, including emphasis on the supervision contract, social justice considerations, ethical guidelines, documentation management, and relational dynamics. Previous research has overwhelmingly demonstrated that a strong supervisory alliance is the bedrock of effective supervision (Bernard & Goodyear, 2019). Sterner (2009) further studied the supervisory relationship as a mediator for supervisee work satisfaction and stress. Lambie and colleagues (2018) developed a CIT clinical evaluation to be used in supervision, with strength in assessing personal dispositions in addition to clinical skills. A review of the supervision literature revealed that a strong supervisory relationship based in goal congruence, empathic rapport, and transparent feedback processes (Bernard & Goodyear, 2019; Borders et al., 2014; Sterner, 2009) generate mutual growth between supervisor and supervisee, enhancing clinical work. Additionally, CACREP mandates that faculty and site supervisors foster CIT professional counselor identity through the supervisory process (Borders, 2006; CACREP, 2015).

Counselor development is also a crucial factor in clinical supervision. An entire category of supervision models centralizes the professional development of supervisees in their approach (Bernard & Goodyear, 2019). One of the most widely known models, the Integrative Developmental Model, plots learning, emotion, and cognitive factors across multiple stages of therapist development (Stoltenberg & McNeill, 2010). By focusing on overarching themes of self–other awareness, autonomy, and motivation, the Integrative Developmental Model (Stoltenberg & McNeill, 2010) illuminates how supervisees fluctuate and grow in their anxiety, self-efficacy, reliance on structure, and independence. All these factors may have substantial impact when considering the complexity that simultaneous supervision brings. Furthermore, professional dispositions of openness to feedback and flexibility and adaptability (Lambie et al., 2018) may have additional developmental implications when considering the complexity of simultaneous supervision.

Ethics similarly serve as a foundation of supervisory experiences. Multiple standards and principles of the ACA Code of Ethics (2014) may be complicated by simultaneous supervision and require special attention. Veracity may be of particular interest given the commonality of supervisee nondisclosure (Kreider, 2014), multiplied by the added number of supervisors in one time period. Furthermore, specific standards in Section D: Relationships With Other Professionals may be implicated by obligations in working with multiple professionals; multiple standards in Section F: Supervision, Training, and Teaching may be indicated because of the convergence of both teaching and clinical supervision in counselor training programs; and, finally, reconciling the additional complexities of simultaneous supervision not explicitly identified elsewhere in the 2014 Code of Ethics may elicit a need to carefully consider Section I: Resolving Ethical Issues. With more parties involved, greater nuance would be expected in ethical decision-making.

Much of the foundational research and reviewed contextual factors have either focused specifically on sole supervision or do not differentiate between sole and simultaneous supervision. When considering best supervision practices, the phenomenon of simultaneous supervision presents distinct practical concerns. Exploration is needed to better understand how supervisees might navigate different but related supervisory relationships, how goals and tasks can be congruent across separate supervisory experiences, and how supervisees would make meaning of multiple sources of feedback. Despite the apparent use of simultaneous supervision in counselor education programs, few researchers have explored these dynamic concerns.

Multiple Supervisors and Multiple Roles
     Early researchers began to conceptualize the challenges and strengths inherent in simultaneous supervision in both counseling (Davis & Arvey, 1978) and clinical psychology (Dodds, 1986; Duryee et al., 1996; Nestler, 1990), with mixed results overall. Nestler (1990) identified the difficulties in receiving contradictory feedback from multiple supervisors, reflective of fundamental differences in the supervisors’ approaches. Dodds (1986) similarly identified multiple potential stressors in having concurrent supervisors at agency and training settings. Dodds argued that although the general goals to teach and serve clients overlapped, each had inherent differences in their primary institutional goals and structures. Duryee and colleagues (1996) described a beneficial view of simultaneous supervision, in which supervisees overcome conflicts with site supervisors via support and empowerment from academic program coordinators. Davis and Arvey (1978) presented a case study in which supervisees, in a raw comparison, more highly favored the dual supervision overall. These findings highlight the dynamics that occur in the context of simultaneous supervision and connect with recent findings.

Recent researchers have focused on dual-role supervision, defined as one individual supervisor serving as both a clinical and administrative supervisor to one or more supervisees (Kreider, 2014). Kreider (2014) investigated supervisee self-disclosure as related to three factors: supervisor role (dual role or single role), supervisor training level, and supervisor disclosure. Level of supervisor disclosure was found to be significant in explaining differences in supervisee self-disclosure and was hypothesized as a mitigating factor in supervisor role differences (Kreider, 2014). Tromski-Klingshirn and Davis (2007) surveyed the challenges and benefits unique to dual-role supervision for post-degree supervisees. Most supervisees reported neutral to positive outcomes from a dual-role supervisor, but a minority of supervisees noted power dynamics and fear of disclosure as primarily problematic (Tromski-Klingshirn & Davis, 2007), similar to the earlier hypotheses of Nestler (1990) and Dodds (1986). The small amount of existing research solidifies the prevalence of simultaneous supervision and the challenges and benefits for the supervisees. A missing link emerges in understanding how CITs come to understand their experience in simultaneous supervision from a qualitative perspective.

The distinct focused phenomenon of simultaneous supervision is limited in counseling literature. The few conceptual examinations of simultaneous supervision in the mental health literature have indicated confusion and role ambiguity (Nestler, 1990), while at other times simultaneous supervision has been noted to improve comprehensive learning (Duryee et al., 1996). Our study addresses the gap in the literature regarding current simultaneous supervision in counselor education utilizing qualitative analysis.


Given the limited research on simultaneous supervision and its prevalence within the profession, we decided to explore this phenomenon qualitatively. Our research question was “What is the experience of CITs receiving simultaneous supervision from multiple supervisors?” We used interpretative phenomenological analysis (IPA) to explore this question because of its utility with counseling research, grounded methods of analysis, and emphasis on both contextual individual experiences with the phenomenon and general themes (Miller et al., 2018).

Research Team
     At the time of the study, the research team consisted of four doctoral students—William B. Lane, Jr., Timothy J. Hakenewerth, Camille D. Frank, and Tessa B. Davis-Price—who each had previous experience with simultaneous supervision as supervisees and supervisors. The team’s perspective of this phenomenon from both roles informed their interest in and analysis of the phenomenon. The fifth member of the team, David M. Kleist, was our doctoral faculty research advisor. The sixth author, Steven J. Moody, provided support in the writing process.

Participants and Procedure
     Our participants were four CITs from CACREP-accredited graduate programs accruing internship hours. Smith et al. (2009) suggested seeking three to six participants for IPA, as this allows researchers to explore the phenomenon with individual participants at a deeper level. All four participants specialized in either addiction, school, or clinical mental health counseling, and identified as White, female CITs ranging from 23 to 37 years old. Additionally, each participant reported receiving supervision from at least two supervisors to include university-affiliated supervisors and site supervisors. Each participant came from a different university representing the Rocky Mountain and North Central regions of the Association for Counselor Education and Supervision. To protect confidentiality, each participant selected a pseudonym for the study.            

After securing approval from our university’s review board, we recruited participants through purposive convenience sampling. We posted a recruitment email to the CESNET listserv, an informational listserv for counselor educators and supervisors. This listserv was selected as an initial step of convenience sampling to increase the potential to reach a broad range of counseling programs. Nine individuals responded to the call to participate in the research by taking a participant screening survey that helped us determine suitability for the study. After removing individuals from research consideration because of potential dual relationships, nonresponse, or not meeting inclusion criteria, four individuals were selected as participants. We further planned to engage in serial interviewing to gain richer details of the phenomenon and achieve greater depth with the four participants (Murray et al., 2009; Read, 2018). Prior to data collection, the researchers completed a brief phone screening with each participant to review the interview protocol and explain the phenomenological approach guiding the questions. A $40 gift card was provided as a research incentive to participants. Our selection criteria included (a) being a master’s student within a CACREP counseling program, (b) currently accruing internship hours, and (c) receiving simultaneous supervision. We selected participants in internship only because homogenous sampling helps produce applicable results for a given demographical experience (Smith et al., 2009).

Data Collection
     Consistent with the recommendations of Smith et al. (2009), we conducted two semi-structured interviews with each participant lasting between 45–90 minutes. We utilized the online videoconferencing platform Zoom to conduct and record the interviews. First-round interviews consisted of four open-ended questions (see Appendix) that allowed participants to explore the experience of simultaneous supervision in detail (Pietkiewicz & Smith, 2014). These questions were open-ended to allow participants to explore the how of the phenomenon (Miller et al., 2018). The final interview questions were developed through initial generation based off research and personal experiences with the phenomenon, refinement in consultation with the research advisor, and interview piloting with volunteer students who did not participate in the study. Research participants were asked about their overall experience with having multiple supervisors, benefits and detriments of simultaneous supervision, and the meaning they made as a result of experiencing simultaneous supervision. Second-round interview questions were developed based on participant responses to first-round interview questions. After two rounds of interviews and analysis, we conducted a final member check to confirm themes. All participants expressed that the developed themes were illustrative of their lived experiences with simultaneous supervision.

Data Analysis
     We followed IPA’s 6-step analysis process as outlined by Smith et al. (2009) and added a seventh step with the use of the U-heuristic analysis for group research teams (Koltz et al., 2010). Our process consisted of first coding and contextualizing the data individually, followed by group analysis, triangulated with the fifth author, Kleist, as research advisor. We completed this process for each participant and then analyzed themes across participants as suggested by Smith et al. We reached consensus that four superordinate themes emerged with 11 subthemes across the two rounds of interviews. All participants endorsed agreement with the themes from their experiences in simultaneous supervision during the member check process.

     We integrated Lincoln and Guba’s (1985) framework in conducting multiple procedures for establishing trustworthiness and credibility. We demonstrated prolonged engagement and persistent observation through consistent coding meetings over the span of 1 year. Additionally, we adapted the U-heuristic analysis process during data analysis to analyze data individually and collectively to strengthen the credibility of our findings (Koltz et al., 2010). Finally, after we developed the themes, we triangulated the results with participants via a member check, ensuring the individual and group themes matched their idiographic experiences.

We bridled our personal experiences with simultaneous supervision throughout the research process. Bridling recognizes that researchers have had close personal experiences with the phenomenon and that bias is best managed by recognition rather than elimination (Stutey et al., 2020). The four principal investigators, Lane, Hakenewerth, Frank, and Davis-Price, individually engaged in memo writing, discussed personal reactions to the data, and participated in group discussions regarding meaning-making of the phenomenon with Kleist serving as research advisor.


Our data analysis produced four superordinate themes identified across all cases. These themes were (a) making sense of multiple perspectives, (b) orchestrating the process, (c) supervisory relationship dynamics, and (d) personal dispositions and characteristics. In the sections that follow, each theme is described in further detail and exemplar quotes are given to support their development.

Making Sense of Multiple Perspectives
     Making sense of multiple perspectives was defined as the receipt and conceptualization of supervisory feedback from multiple supervisors during the same academic semester. Supervisees identified their supervisors as having differing professional orientations. At times, these differing backgrounds led to supervisors providing differing opinions for the same client.

Participants used metaphors to make meaning of the distinct offerings of their supervisors’ feedback. An example of capturing multiple perspectives was one participant, Emma, utilizing the ancient Indian parable of “The Blind Men and the Elephant” (Saxe, 1868): “The point of the story is all the world religions might have a piece of the picture of God, you know. And so between all of us [clinicians and supervisors] together, maybe we have a perspective of truth.” Through retelling of the Indian fable, this participant was able to vividly capture her personal perspective of differing viewpoints through an integrative lens as opposed to a conflict of ideas. Within this superordinate theme, the two subthemes of supervisee framing and safety net vs. minefield emerged.

Supervisee Framing
     Supervisee framing focused on the participant’s personal view of hearing multiple perspectives from supervisors within simultaneous supervision. Some participants described hearing varying perspectives as being helpful and valuable, providing support, and increasing confidence. They typically framed the idea of receiving various feedback as a way to gain ideas and then make their own informed decisions. Molly shared this positive perspective when she stated, “I like coming to [my differing supervisors] with different issues I have with different clients because I feel like they both have valuable experience, but in different ways.” In contrast, Hailey identified multiple perspectives as being “really difficult,” and Diana noted they were “more frustrating than beneficial” and confusing. Similarly, Hailey stated, “My supervisors are all very different, so they give me different feedback, and a lot of times it conflicts with what the other one has said.” The supervisee’s framing of discrepant feedback impacted their overall perceptions with simultaneous supervision. Supervisees either valued or were confused by the feedback. Generally, participants spoke of times when multiple perspectives were beneficial and difficult, but it appeared all participants were left with the task of making sense of multiple perspectives while receiving simultaneous supervision.

Safety Net vs. Minefield
     Making sense of multiple perspectives was described as creating a safety net of support, while others found the experience to be a minefield that increased confusion, ambiguity, and isolation. Emma and Molly characterized their experience as providing support in an often overwhelming profession. Molly articulated, “I feel like if I didn’t have that good support, that good foundation, I don’t think I could do it because it’s just so much.” She later added, “I feel like getting those different perspectives, getting that support, getting those encouragers is beneficial because I don’t feel as overwhelmed, even though it’s overwhelming.”

Participants also perceived their simultaneous supervision as a minefield wherein they believed they were in double binds. Hailey reflected on an experience when her supervisors contradicted each other and expressed, “It just sucked because I was doing what my supervisor told me to do and suggested I do, and then I was told everything I did was wrong.” Diana echoed that discrepant feedback felt like a constant dilemma needing to be managed “carefully.” In reflecting on contradicting supervision, Diana said, “It’s hard because everybody has their own thing. . . . You just kind of have to appease everyone.” In the face of conflict, it was easier to placate than resolve. Participants’ cognitive framing was a major element of the phenomenon. Whereas making sense of multiple perspectives focused on the cognitive elements of receiving feedback from different supervisors, the next theme focused on the behavioral elements.

Orchestrating the Process
     Another theme that emerged in our data analysis was that of supervisees orchestrating the process of simultaneous supervision. This theme revolved around action-oriented steps in supervision. The essence of this theme was captured when Hailey acknowledged the need for “checking her motives” on what she shared with different supervisors. She asked herself, “Am I sharing this with this [supervisor] because I feel like they’re going to answer in the way that I feel like . . . they should answer, because it’s easier for me?” Hailey acknowledged the difficulty in this, countering with, “Or am I just going to them because it’s that person that I’m supposed to see?” Hailey recognized that having options when it came to approaching supervisors meant that disclosure needed to be intentional rather than straightforward as it is when CITs only have one choice. Participants were aware of their process as they picked and chose what to share with whom, through seeking out a preferred supervisor and through managing the practical aspects of having multiple supervisors. The subthemes of picking and choosing, seeking a preferred perspective, and managing practical considerations were a part of orchestrating the process.

Picking and Choosing
     The subtheme of picking and choosing emerged in how our participants described what they would share in supervision and the course of action taken in their counseling practice. This subtheme was labeled as an in vivo code, derived from Hailey’s quote: “So I definitely pick and choose what I talk to about each one. Because—this sounds terrible—but I respect the one [supervisor] more.” Hailey also described feelings of vulnerability and self-efficacy from week to week, related to her reactions from feedback: “I knew after having such a hard supervision last week showing tape, I was like, ‘I cannot be super vulnerable right now. I need to choose something that’s more surface level.’” Molly experienced picking and choosing as a means of proactively managing the repetitive nature of supervision: “I think just bringing different things to different supervisors is really helpful, and not constantly talking about the same client or the same situation, because that gets obnoxious and repetitive, and you’re gonna get a hundred different opinions.”

After receiving feedback, participants had varying perspectives on how to integrate and transfer constructs into action. Some participants viewed discrepant feedback as mutually exclusive, whereas others had a more integrative perspective. Molly expressed frustration in choosing between differing feedback from multiple supervisors: “Sometimes I don’t really know which I should go with, which I should choose, and which would be best for the client. . . . It’s like a double-edged sword, like it’s good at some points, but then bad at others.” Diana, who expressed similar frustration in choosing between perspectives, relieved this tension by resolving that, “I have to live with myself at the end of the day, so as long as it’s not unethical, I don’t worry about it too much.  And as far as the stuff that I’m told that needs to be done, I do what I can.” Other participants espoused a much more integrative perspective. Emma stated, “I think the thing I like the best about it is actually when [my supervisors] have different advice . . . because then I feel like between the two, I can kind of find what I really like.” All participants spoke about selecting what to share with supervisors and choosing how to integrate feedback into action.

Seeking a Preferred Perspective
     Coinciding with picking and choosing, participants also sought a preferred perspective in the process of receiving simultaneous supervision and orchestrating the process. Some reported the decision to go to one supervisor over another was situationally based and determined by clinical skill or specialty of the supervisor. Diana captured this as follows, “Well, I can have a conversation with either. I just get very different answers. If it’s the technical stuff of what has to be done—her. If it’s ‘how would you approach the situation?’ I do tend to talk to him.” Diana also likened seeking a preferred perspective to a child searching for a desired answer: “It’s like, who do I want to talk to? It’s almost like, talk to the person you want for the answer you want. It’s like, ‘Well, if Mom doesn’t have the right answer, go talk to Dad.’”

Managing Practical Considerations
     All participants spoke to the practicality of meeting with multiple supervisors. Even though some participants strongly valued having multiple supervisors, all participants spoke to the larger time commitment needed in having simultaneous supervision. Molly captured how simultaneous supervision felt overwhelming, adding to the many other sources of feedback she received: “I already have two group supervisions. I’ve heard opinions about this, and I’m hearing other perspectives of my classmates, of my coworkers. Now I have to have triadic and hear their opinions and have individual. . . . It’s just a lot.” Emma framed this time commitment as detracting from her other obligations: “It just starts adding up. Like, my whole Tuesday evenings are gone, and that’s time I could be seeing clients.” Hailey expressed frustration about the obligatory nature and placating to the program’s requirement to see multiple supervisors: “Honestly, I just give the other supervisor little things because I know I have to talk to him . . . and it’s more, like, checking a box.” Finally, Emma captured how this time commitment was epitomized in documentation: “And the paperwork got exhausting, too, because I had to do everything in triplicate sometimes.” She further talked about the additional mental labor: “And now what are we gonna talk about since I just talked about all of this with [a different supervisor] and feel like I found good solutions, you know?” Supervisees had to manage their time and fit more supervision into their schedules. Simultaneous supervision added complexity, and participants needed to orchestrate this process to manage it efficiently and effectively.

Supervisory Relationship Dynamics
     Supervisory relationship dynamics was determined to be a superordinate theme as it reflected on the connecting and disconnecting elements of the supervisory relationship. This theme was broken into three subthemes. The subthemes of vulnerability, power dynamics, and systems of supervision illustrated the relational dynamics within simultaneous supervision.

     In supervisory relationships, feelings of safety and vulnerability influenced interactions with different supervisors. To illustrate, Hailey noted:

There are certain supervisors I feel more safe with. And so those are the ones that I share more with . . . versus some of them I feel less safe with . . . I don’t share as much with them that is vulnerable, or that makes me vulnerable.

Participant experiences highlighted how vulnerability dictated what and how elements were shared in simultaneous supervision. 

Power Dynamics
     The determination of safety occurred within power dynamics. Diana commented that multiple supervisors serving as evaluators and gatekeepers can create “this weird relationship where you don’t want to be too vulnerable because this person is also your boss and can decide if you are going to stay in that position or not.” Diana and Hailey noted feeling disempowered and disengaged from supervision, referring to supervisors as “bosses” throughout their interviews. When participants perceived their supervision as a firmly directive process, discrepant directives were especially distressing. Diana rephrased this sentiment: “I guess the best thing to compare it to would be if you have more than one boss, but they all give you a different, ‘I want this, I want this, I want this.’” Emma’s experience was more accordant, and she specifically expressed at one time, “None of [my supervisors] are really super bossy either.” Participants identified power dynamics as salient aspects of how they experienced supervision and with whom they connected. Working with more than one supervisor sometimes resulted in characterization of “good” and “bad” supervisors, making individual supervisory relationship dynamics crucial.

Systems of Supervision
     Participants conceptualized the phenomenon as broader systems of supervision in which individual supervisors were interacting with each other. Emma noted, “The two faculty supervisors work very closely together and I assume talk all the time.” Emma and Molly provided multiple examples of supervisors working together to best serve clients, thus bolstering supervision through their combined expertise. Molly stated, “It was nice because [my two supervisors] were in agreement and I felt comfortable going into session with [my client].” Even negative experiences contributed to systems of supervision. Hailey reported seeking out additional support when her assigned supervisory relationships did not meet her needs, widening the reach of simultaneous supervision even more: “By not being a good supervisor, he helps me seek out other resources and figure it out for myself.” Finally, Molly noted that supervisor coordination was primarily for evaluation at the end of the semester and only if problems arose. However, she imagined what it would be like if they were more collaborative:

They would have had a better understanding of the way I work in a counseling room. . . . Because my site supervisor really understood how I approached things and the way I would interact with my clients, but I feel like my university supervisor didn’t really, like, she had little snippets of what I was like in a counseling room.

Power, vulnerability, and systems in the supervisory relationship impacted supervisees from multiple levels in their clinical journey.

Personal Dispositions and Characteristics
     Personal dispositions and characteristics resulted from participants speaking about the phenomenon as well as what they said about their supervisors. Three dispositions that emerged as relevant were tolerance for ambiguity, curiosity, and availability. The first two subthemes were identified as they spoke about the phenomenon and the third subtheme was a characteristic present because of the nature of simultaneous supervision.

Tolerance for Ambiguity
     Tolerance for ambiguity was found to be a critical disposition. This disposition allowed participants to see differences in opinion as helpful. Emma shared that she “very rarely” saw people as giving her “conflicting information.” She said that she saw it as everybody having their own perspective. This connected to her ability to view multiple perspectives as “pieces of the puzzle,” as she expressed earlier in her retelling of the Indian fable. Although participants sometimes expressed concern about direction, Diana shared, “You can ask questions and you can not know and it’s okay.” This disposition directly related to how they reconciled and then reacted to multiple perspectives of simultaneous supervisors.

     Curiosity also manifested more implicitly with supervisees. Participants showed curiosity by taking interest in what supervisors had to say, seeking more information, or staying open to difficult feedback. Hailey shared that simultaneous supervision “definitely requires a lot of continuing to look inward and examining your motives and yourself and what the supervisors have said.” In speaking more broadly, Emma shared, “So I don’t think I’ll ever give [simultaneous supervision] up now that I’ve kind of experienced how valuable it is to get another professional opinion.” Curiosity manifested itself as a transient characteristic for other participants. Diana experienced transference with one of her supervisors, which was a barrier to her ability to exhibit this helpful disposition. One of her supervisors suggested that she try and work things out with another supervisor she was having difficulty with, to which Diana said, “No. Who is gonna walk into their supervisor and be like, ‘Okay, so my problem with you is you’re a bitch. You remind me of my abusive ex.’ . . . But at the same time, I have to work with her.” This was an example of Diana demonstrating a closing off to feedback. Both tolerance for ambiguity and curiosity manifested and impacted their experience of multiple perspectives.

     An important disposition was emotional and physical availability. Emma expressed that “there’s always somebody I can get a hold of.” Hailey expressed that she had “more coverage just in general,” but also questioned her supervisors’ true availability: “Do I even need to bring this to supervision or can I work on this on my own? Because sometimes I feel like I annoy them.” All participants expressed that availability was important to their experience, although physical availability did not always translate to being available to discuss what the supervisee wanted. Those participants who identified supervisors within simultaneous supervision as being more available had more positive thoughts regarding simultaneous supervision.


All four participants identified the complex position of CITs receiving supervision from more than one supervisor. The results align with the growing body of literature affirming the importance of a positive working relationship between CITs and supervisors (Bernard & Goodyear, 2019; Borders et al., 2014; Sterner, 2009) as well as significant differences between faculty and site supervision (Borders, 2006; Dodds, 1986). The results parallel supervision literature detailing the multiple roles of supervisees (Bernard & Goodyear, 2019) who, unlike supervisors, are not required to have specific education in supervision. The theme of personal dispositions has been studied extensively in counselor education, resulting in prominent placement in clinical assessment instruments (Lambie et al., 2018). The presented themes diverge from the current research base in their construction of a clear model of simultaneous supervision. The subthemes of picking and choosing, seeking a preferred perspective, and systems of supervision illustrate the interpersonal dynamics of simultaneous supervision that is distinct from sole supervision, an underrepresented phenomenon in the supervision literature. Participants in this study reported mixed feelings with simultaneous supervision. Four primary themes emerged from this study: making sense of multiple perspectives, orchestrating the process, supervisory relationship dynamics, and personal dispositions and characteristics. These four themes encompass many areas of the supervisory experience while illuminating guidelines for supervisors engaging in simultaneous supervision.

     Results from this study reinforce the complex levels of integration CITs experience when receiving supervision from multiple supervisors. This process of integration can lead to confusion, ambiguity, and also deeper understanding. The results indicate that the perceived benefit of simultaneous supervision was often based on the relationship between the supervisor and CIT, ability and support to organize the process, and the personal dispositions of the CIT. The implications for this research target three populations.

     The findings of this study indicate several implications for supervisors working with clinicians receiving simultaneous supervision. First and foremost, the critical importance of the supervisory relationship to supervision in general (Bernard & Goodyear, 2019) was further substantiated as a foundation for effective simultaneous supervision. Questionable supervisee behaviors such as intentional nondisclosure via seeking a preferred perspective or picking and choosing can be avoided through purposefully fostering trust in the relationship. Similarly, supervisors may support the perspective of simultaneous supervision as a safety net if support for vulnerability is established and the relationship is actively attended to. Supervisors should be mindful of their availability to CITs and periodically check in to see if they are meeting the needs of the supervisee.

Supervisors who are aware of the themes developed from this research may be better equipped to capitalize on benefits and mitigate challenges. One benefit was that simultaneous supervision allowed participants to receive multiple synergistic perspectives regarding their work with clients. Depending on the developmental level of the supervisee and the demeanor of the supervisor, however, these multiple perspectives may present challenges. Supervisors can apply their knowledge of developmental models to tailor their interventions. Supervisors might anticipate that CITs earlier in development (e.g., in practicum) may require structured support in simultaneous supervision to avoid performance anxiety and frustration from rigid applications of multiple perspectives consistent with this stage (Stoltenberg & McNeill, 2010). Supervisors may also wish to focus supervision on interventions that actively facilitate development of these dispositions, such as employing constructivism to elicit greater cognitive flexibility (Bernard & Goodyear, 2019).

Some early-stage supervisees may experience challenges when navigating varying perspectives and feedback provided to them by multiple supervisors. Challenges can be mitigated when supervisors broach the topic of simultaneous supervision with supervisees early. Additionally, when supervisors ensure they respect other supervisors and create collaborative relationships, supervisee difficulty with simultaneous supervision may decrease. When a supervisor learns of a differing opinion of another supervisor, it is important that it is broached as a variance in approach rather than an incorrect practice. Supervisees experiencing difficulties with simultaneous supervision may also benefit from supervisors checking in with them regarding the variable feedback they are receiving. A collaborative supervisory system may strengthen supervisee development and integration of counseling constructs. Counseling programs can play a key role in setting systemic expectations for supervisors and supervisees.

Counselor Education Programs
     Accredited counselor education programs have autonomy in how they meet various CACREP (2015) supervision and clinical requirements. Programs may choose to require simultaneous supervision, may require multiple clinical sites, and may utilize faculty advising as supplementary clinical supervision. In unique situations such as students completing two tracks or receiving additional supervision for gatekeeping reasons, how programs manage simultaneous supervision can become complex. Best practice guidelines, policies, and procedures regarding simultaneous supervision can be made clear in clinical handbooks, with clinical coordinators, and in material for site supervisors. This would help to address the supervisee confusion from the programmatic side. Another important implication with simultaneous supervision is to consider the supervisory process through a systemic lens. When simultaneous supervision is utilized, there will be many interactions occurring outside of the dyad or triad apparent to one individual supervisor. When supervisors collaborate and communicate, supervisees may be more likely to receive congruent feedback, understand gatekeeping action, and receive consistent expectations. In particular, communication between academic and clinical supervisors can bridge the gap between idealism and practicality (Bernard & Goodyear, 2019; Choate & Granello, 2006). Programmatically mandated, semesterly site visits and opportunities for regular check-ins could fulfill this purpose.

     Participants often spoke to the challenge of organizing simultaneous supervision effectively in relation to feedback, documentation, and case presentation material. Although a certain level of organizational skill is expected of graduate students, the coordination required in simultaneous supervision often seemed unanticipated and unwieldy for students. Preparing for the supervision experience in another course and/or an orientation in lab supervision may aid in this. All participants discussed, at varying distress levels, how having supervision scheduled too close together (e.g., same day or two days in a row) increased repetitiveness and thus made simultaneous supervision feel less efficacious. Supervisees may want to intentionally schedule supervision sessions spaciously to avoid potential repetition or redundancy. With the steady increase in virtual supervision, scheduling supervision in ideal time frames may be easier with increased access and absent travel time. Programmatic preparation, intentional scheduling, and collaborative supervision notes may aid the simultaneous supervision process.

In the areas of core dispositions, CITs who embraced ambiguity and fostered reflexivity, curiosity, and flexibility tended to navigate simultaneous supervision with more ease. Reflexivity, curiosity, and tolerance for ambiguity seemed to strengthen the ability to receive feedback from multiple sources, integrate feedback appropriately, and maintain strong supervisory relationships. A typical guiding question from participants was, “How can I apply this combined feedback to my particular site and client while still maintaining my own clinical identity?” Necessarily, students will enter a program with differing levels of core strengths, yet any student can be encouraged to strengthen their core dispositions. Supervisees are encouraged to think about simultaneous supervision with the same organization and openness required for other courses such as pre-practicum and multicultural counseling. Correspondingly, supervisors have complex responsibilities maintaining ethical competent care, organizing supervision, and fostering these core dispositions.

Ethical Implications of Simultaneous Supervision
     In addition to recommendations for the three populations above, findings from this study highlight ethical considerations. Worthington et al. (2002) identified “intentional nondisclosure of important information” (p. 326) and “inappropriate methods of managing conflict with supervisors” (p. 329) as two major ethical issues that are unique to supervisees and correlate with some of the participant supervisees’ experiences of triangulating supervisors, seeking outside consultation to circumvent supervisors, or intentionally withholding information. To ensure client welfare, supervisors and supervisees may benefit from explicitly discussing ethical implications and considerations unique to this phenomenon at the outset of supervision and again when conflicts arise. Future research that addresses limitations of this study will further clarify the role of supervisors, supervisees, and programs in simultaneous supervision as well as specific ethical guidelines.

Limitations and Future Directions
     Limited information was gathered about the specific counselor education programs in which our participants were enrolled, restricting the inferences able to be made about simultaneous supervision in context. We also chose a convenience sampling method using CESNET and selected four participants. The choice of indirect sampling, primarily through counselor educators redirecting calls to their students, may have limited participants. Further, all participants of this study identified as the same gender and race, which limits the diversity of experience shared. Future researchers may consider sampling more participants to get a broader exploration of the phenomenon. In doing so, researchers may be able to obtain greater representation in gender and race to increase the transferability of this study.

This study focused on the phenomenon of simultaneous supervision as experienced within individual and triadic supervision. Simultaneous supervision is embedded within the broader experience of supervision, and isolating the phenomenon required vigilance by the researchers. Future researchers would benefit from intentional follow-up questions that better focus participants on simultaneous supervision rather than individual experiences with supervisors. As our study did not explicitly ask participants to distinguish between university-affiliated and site supervisors, future researchers may pursue a qualitative study that highlights the difference. Other research may utilize grounded theory to develop a model of simultaneous supervision for supervisors and supervisees to follow or focus explicitly on supervisors’ perspectives of simultaneous supervision. Quantitative research may illuminate the frequency and use of simultaneous supervision in counselor education programs overall or identify correlations between counselor dispositions such as tolerance for ambiguity and supervision outcomes in simultaneous supervision. Because of the lack of information regarding the phenomenon of simultaneous supervision, many opportunities for research regarding the phenomenon persist.


Overall, the findings from this research indicate CITs valued greater support and thrived when integrating “both/and thinking” in navigating feedback from multiple supervisors. This perspective reinforces the need for systemic communication among counselor educators and supervisors. Additionally, results suggest CITs would benefit from supervisors broaching the topic of simultaneous supervision early in their clinical experience.

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



American Counseling Association. (2014). ACA code of ethics.

Bernard, J. M., & Goodyear, R. K. (2019). Fundamentals of clinical supervision (6th ed.). Pearson.

Borders, L. D. (2006). Snapshot of clinical supervision in counseling and counselor education: A five-year review. The Clinical Supervisor, 24(1–2), 69–113.

Borders, L. D., Glosoff, H. L., Welfare, L. E., Hays, D. G., DeKruyf, L., Fernando, D. M., & Page, B. (2014). Best practices in clinical supervision: Evolution of a counseling specialty. The Clinical Supervisor, 33(1), 26–44.

Choate, L. H., & Granello, D. H. (2006). Promoting student cognitive development in counselor preparation: A proposed expanded role for faculty advisers. Counselor Education and Supervision, 46(2), 116–130.

Council for the Accreditation of Counseling and Related Educational Programs. (2015). 2016 CACREP standards.

Davis, K. L., & Arvey, H. H. (1978). Dual supervision: A model for counseling and supervision. Counselor Education and Supervision, 17(4), 293–299.

Dodds, J. B. (1986). Supervision of psychology trainees in field placements. Professional Psychology: Research and Practice, 17(4), 296–300.

Duryee, J., Brymer, M., & Gold, K. (1996). The supervisory needs of neophyte psychotherapy trainees. Journal of Clinical Psychology, 52(6), 663–671.

Koltz, R. L., Odegard, M. A., Provost, K. B., Smith, T., & Kleist, D. (2010). Picture perfect: Using photo-voice to explore four doctoral students’ comprehensive examination experiences. Journal of Creativity in Mental Health, 5(4), 389–411.

Kreider, H. D. (2014). Administrative and clinical supervision: The impact of dual roles on supervisee disclosure in counseling supervision. The Clinical Supervisor, 33(2), 256–268.

Lambie, G. W., Mullen, P. R., Swank, J. M., & Blount, A. (2018). The Counseling Competencies Scale: Validation and refinement. Measurement and Evaluation in Counseling and Development, 51(1), 1–15.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. SAGE.

Miller, R. M., Chan, C. D., & Farmer, L. B. (2018). Interpretative phenomenological analysis: A contemporary qualitative approach. Counselor Education and Supervision, 57(4), 240–254.

Murray, S. A., Kendall, M., Carduff, E., Worth, A., Harris, F. M., Lloyd, A., Cavers, D., Grant, L., & Sheikh, A. (2009). Use of serial qualitative interviews to understand patients’ evolving experiences and needs. BMJ, 339, b3702.

Nestler, E. J. (1990). The case of double supervision: A resident’s perspective on common problems in psychotherapy supervision. Academic Psychiatry, 14(3), 129–136.

Pietkiewicz, I., & Smith, J. A. (2014). A practical guide to using interpretative phenomenological analysis in qualitative research psychology. Psychological Journal, 20, 7–14.

Read, B. L. (2018). Serial interviews: When and why to talk to someone more than once. International Journal of Qualitative Methods, 17(1), 1–10.

Saxe, J. G. (1868). The poems of John Godfrey Saxe. Ticknor and Fields.

Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method and research (1st ed.). SAGE.

Sterner, W. (2009). Influence of the supervisory working alliance on supervisee work satisfaction and work-related stress. Journal of Mental Health Counseling, 31(3), 249–263.

Stoltenberg, C. D., & McNeill, B. W. (2010). IDM supervision: An integrative developmental model for supervising counselors and therapists (3rd ed.). Routledge.

Stutey, D. M., Givens, J., Cureton, J. L., & Henderson, A. J. (2020). The practice of bridling: Maintaining openness in phenomenological research. The Journal of Humanistic Counseling, 59(2), 144–156.

Tromski-Klingshirn, D., & Davis, T. E. (2007). Supervisees’ perceptions of their clinical supervision: A study of the dual role of clinical and administrative supervisor. Counselor Education and Supervision, 46(4), 294–304.

Worthington, R. L., Tan, J. A., & Poulin, K. (2002). Ethically questionable behaviors among supervisees: An exploratory investigation. Ethics & Behavior, 12(4), 323–351.


William B. Lane, Jr., PhD, NCC, BC-TMH, LPCC, is an assistant professor at Western New Mexico University. Timothy J. Hakenewerth, PhD, NCC, LPC, is an assistant professor at the University of Illinois Springfield. Camille D. Frank, PhD, NCC, LMHC, LPC, is an assistant professor at Eastern Washington University. Tessa B. Davis-Price, PhD, LMHC, LCPC, is an assistant professor at Saint Martin’s University. David M. Kleist, PhD, LCPC, is a professor and department chair at Idaho State University. Steven J. Moody, PhD, is a clinical professor at Adams State University. Correspondence may be addressed to William B. Lane, Jr., 1000 W College Ave, Silver City, NM 88061,



Interview Protocol

Interview Questions
Round 1
What has been your experience with having multiple simultaneous supervisors?

In your own experience, how has simultaneous supervision been a strength?

In your own experience, how has simultaneous supervision been challenging?

What have you learned about yourself and the counseling profession as you’ve experienced simultaneous supervision?

Round 2
How has having simultaneous supervision been different from times when you have only had one supervisor?

What has it been like to have your supervisors interact with each other in regard to the supervision that you have received from them?

What personal dispositions (characteristics/qualities) do you think you have that influenced your experience of simultaneous supervision?

How has simultaneous supervision impacted your experience of safety or vulnerability in supervision?

What practical considerations have you needed to consider for having multiple simultaneous supervisors?


Body Neutral Parenting: A Grounded Theory of How to Help Cultivate Healthy Body Image in Children and Adolescents

Emily Horton

Body neutrality is a concept wherein individuals embody a neutral attitude toward the body that is realistic and flexible, appreciate and care for the function of the body, and acknowledge that self-worth is not defined by one’s outward appearance. Family behavior regarding body image has been related to higher levels of body dissatisfaction and unhealthy eating behavior among children and adolescents. Caregivers need knowledge and support on how to cultivate healthy body image for their children and adolescents. Limited studies explore how to parent in a way that promotes healthy relationships with one’s body, food, and exercise. I conducted a grounded theory study to explore the experiences of caregivers who integrate tenets of body neutrality. Semi-structured interviews were conducted with 10 caregivers of children and adolescents who self-identified as approaching parenting from a place of body neutrality. Through constructivist grounded theory, I discerned insights regarding how caregivers can support their children and adolescents in developing healthy relationships with their bodies and how this corresponds with self-esteem. Considerations for counselors using body neutrality to support children, adolescents, and caregivers are provided. 

Keywords: body neutrality, body image, parenting, children and adolescents, self-esteem

Body image and related low self-esteem are frequently under-addressed or unaddressed in counseling children, adolescents, and their caregivers (Damiano et al., 2020). Too often, counselors may take a reactive approach to addressing unhealthy relationships with food, bodies, and exercise in the family system, such as counseling after an adolescent is diagnosed with an eating disorder (Liechty et al., 2016). Thus, counselors may benefit from considering how to take a preventative, proactive approach to supporting children’s mental health specific to their relationship with food, bodies, and movement (Siegel et al., 2021). Because the family system has tremendous impact on children’s body image and relationship with food, counselors need to consider how to provide appropriate psychoeducation and support to caregivers on how to manage food and body talk (Gutin, 2021). Positive caregiver influence on body image can prevent disordered eating, negative body image, and low self-worth, and many families need a licensed mental health professional to cultivate said positive influence (Veldhuis et al., 2020).

Researchers have found that children as young as 3 to 5 years old experience body image issues (Damiano et al., 2015; Dittmar et al., 2006). Caregivers often communicate body dissatisfaction, engage in dieting, and demonstrate a drive for thinness, messages that children can internalize (National Eating Disorders Association, 2022). Families can inadvertently pass down unhealthy ideals regarding body image to their children (Kluck, 2010). Kluck (2010) emphasized that a family’s focus on appearance was related to their child’s body image dissatisfaction, and the dissatisfaction predicted increased disordered eating. Counselors with appropriate training can play an important role in mitigating the harmful cycle before disordered thinking turns into disordered eating (Klassen, 2017). Counselors have the unique opportunity to support families in encouraging a healthy relationship with their bodies (Horton, 2023; Horton & Powers, 2024).

In this study, I sought to explore the experiences of caregivers who integrate tenets of body neutrality. Body neutrality is a concept wherein individuals embody a neutral attitude toward the body that is realistic and flexible, appreciate and care for the function of the body, and acknowledge that self-worth is not defined by one’s outward appearance (Pellizzer & Wade, 2023). Examples of body neutrality can include not describing food as healthy or unhealthy, talking about what our bodies do for us rather than what they look like, and moving for enjoyment rather than to burn calories. Because the tripartite model emphasizes that parental influence, in addition to peer and media influence, is significant for children’s body image development, I explored existing research on parental influence on body image and self-esteem (Thompson et al., 1999).

Parental Influence on Body Image and Self-Esteem

Some family members negatively impact children’s and adolescents’ body image (Pursey et al., 2021). Neumark-Sztainer et al. (2010) found that over half of the adolescents in their study experienced weight-based and appearance-based teasing from family, and these experiences correlated to higher levels of body dissatisfaction, disordered eating, and related mental health difficulties, such as depression. Parental influence on body image includes both direct (e.g., criticism about their child’s weight) and indirect (e.g., parents’ attitudes about their own bodies, food, and exercise) behaviors (Rodgers & Chabrol, 2009). Abraczinskas and colleagues (2012) conducted a study exploring parent direct influence, including weight- and eating-related comments, and modeling, including parental modeling of dieting and related behavior. In the study of over 360 participants, Abraczinskas and colleagues found that parental influence is a risk factor in the development of a drive for thinness, body shape dissatisfaction, and eating disorder symptomology.

Moreover, Wymer and colleagues (2022) emphasized the importance of parent engagement in body image and self-esteem development. Often, families recognize the importance of discussing body image with their children but do not feel confident or competent in doing so (Siegel et al., 2021). The lack of confidence and competence leads to messages about health being conflated with messages about thinness (Siegel et al., 2021). In addition, researchers highlighted that although parental influence has a significant impact on body image and self-esteem, siblings, friends, and the media are also perceived to have influence over youth’s feelings about their bodies (Ricciardelli et al., 2000). The exiguous literature on parental influence on body image repeatedly emphasizes the negative impact of parents on body image yet seldom explores preventative and therapeutic ways of promoting healthy body image (Phares et al., 2004). Thus, I sought to explore how counselors might integrate body neutrality when supporting families and provide early intervention and prevention for adverse relationships with food, body, and movement.

Body Neutrality

Body neutrality is a concept wherein individuals accept their bodies as a vessel that carries them through life, and as such, do not attach positive or negative feelings to their physicality. For example, body neutrality can entail nurturing and respecting the body, being mindful of body talk, engaging in body gratitude and functionality appreciation, and recognizing self-worth that is not focused on appearance (Pellizzer & Wade, 2023). Body neutrality is an approach taken to help with the healing of body image, particularly in the field of eating disorders (Perry et al., 2019). Body neutrality tenets appear to be integral in the prevention of body image dissatisfaction and disordered eating (Herle et al., 2020). Practicing body neutrality positively impacts body satisfaction, self-esteem, and negative affect with adults, though continued empirical research is needed on its impact with youth (Walker et al., 2021). Although counselors and other allied professionals integrate body neutrality into their clinical practice, there is minimal research on its efficacy outside of eating disorder treatment. Existing research has emphasized the need for counseling approaches with youth that highlight body neutrality tenets, such as mindful eating and awareness-building conversations about societal messaging (Klassen, 2017). However, researchers have yet to explore how body neutrality could be integrated into a parenting approach. The bulk of the limited understanding of body neutrality is treatment based, rather than prevention oriented.

Thus, the purpose of this study was to cultivate a grounded theory or an abstract theoretical understanding of body neutral parenting (Charmaz, 2014). Further insight into the experiences, challenges, and potential barriers in parenting with body neutrality can enable a deeper understanding of how parents seek to promote healthy body image and self-esteem for children and adolescents. In this study, I aimed to offer a newfound understanding to mental health professionals supporting children, adolescents, and caregivers in the areas of body, food, movement, and related mental health implications.


     To address the paucity of literature, a grounded theory study was conducted to examine the following research question: How do caregivers conceptualize and actualize body neutral parenting with their children? The study derived from constructivist grounded theory (CGT; Charmaz, 2014). CGT is an interpretative, qualitative methodology that acknowledges that researchers and participants co-create the theory (Charmaz, 2014). Given a desire to understand how caregivers conceptualize and utilize body neutral parenting, CGT was deemed appropriate. The purpose of the study was to generate a new theory through inductive analysis of data gleaned from caregivers who self-identify as using body neutral parenting.

Role of the Researcher
     Congruent with CGT, I maintained a position of distant expert (Charmaz, 2014). The theoretical meaning was constructed by turning participants’ experiences into digestible theoretical interpretations. While staying as true to the experiences of the participants as possible, I reconstructed the participants’ stories in the development of the grounded theory via balancing conceptual analysis of participants’ stories and creating a sense of their presence in the narrative (Mills et al., 2006). I sought to examine the impact of my privilege and preconceptions as a White, cisgender woman and professional in the field of mental health counseling, with experience supporting families navigating eating disorders and disordered eating (Charmaz, 2014). Also, as a parent who integrates body neutrality into my approach with my child, I practiced reflexive journaling and other trustworthiness strategies to bracket my biases throughout the study.

Participant Recruitment
     I obtained IRB approval prior to data collection. Per the IRB, all participants verbally consented before partaking in the research study. I used purposive sampling (Patton, 2014) for participant selection. Selection criteria included: (a) being a caregiver to at least one child under the age of 18, (b) identifying as integrating body neutrality into their parenting approach, and (c) willingness to participate in an interview lasting roughly 1 hour. I circulated electronic flyers detailing the focus of the study to social media pages for caregivers and professional networks. The recruitment flyers provided examples of body neutral parenting, including not describing food as healthy or unhealthy, talking about what our bodies do for us rather than what they look like, and moving for enjoyment rather than to burn calories.

Ten participants were interviewed. Of the 10 participants, nine identified as cisgender women and one identified as nonbinary. All 10 participants described themselves as being middle class. Nine participants were married and one was single. All of the participants had graduate-level or doctorate-level educations; four had master’s degrees and six had doctoral degrees. Participants lived in seven different states and two different countries. Participants had at least one child, with the number of children ranging from 1 to 5. Table 1 provides detailed demographic data.

Table 1
Participants’ Demographic Data

Pseudonym Age Race Number

of Children

Age of Children Race of Children
Logan 27 White 1 20 months White
Esmeralda 38 Hispanic 2 8 and 5 years White
Imani 29 Black, White 2 6 and 3 years White
Kimberly 33 White 2 5 and 2 years White
Heather 42 White 2 3 years, 8 months White
Cassie 45 White 5 16, 13, 11, 9, and 7 years White
Shanice 36 African American 4 15, 9, and 2 years; 4 months African American
Scarlett 36 White 3 17, 5, and 4 years White
Leilani 43 White 1 9 years Polynesian, White
Jennifer 36 White 1 2 years Middle Eastern, White

Data Collection and Analysis
     As guided by Charmaz’s (2014) CGT protocol, data collection and data analysis proceeded simultaneously, and the inclusion criteria evolved to include caregivers with children of all ages. The semi-structured interviews occurred via confidential videoconferencing software and lasted between 60 and 75 minutes. Interviews were an open-ended, detailed exploration of an aspect of life in which the participants had substantial experience and considerable insight: parenting with body neutrality principles (Charmaz & Liska Belgrave, 2012). During the interviews, I inquired about caregivers’ experiences, challenges, and insights of body neutral parenting. With the emergent categories, the guide evolved to emphasize the nuances of the parenting approach in alignment with three-cycle coding or focused coding (Charmaz, 2014).

Grounded theorists try to elicit their participants’ stories and attend to whether the participants’ interpretations are theoretically plausible (Charmaz & Liska Belgrave, 2012). As such, the interview protocol began with an initial open-ended question: “Tell me about a time in which you used body neutral parenting.” Then, I asked intermediate questions, such as “How, if at all, have your thoughts and feelings about body neutral parenting changed since your child was born?” I also asked ending questions, including: “How has taking the approach with your children impacted you as a parent? As a person?” The interview questions were informed by the literature and were reviewed by another content matter expert.

In addition to the in-depth interview, I used information from other data sources to support the depth of the data and theory construction. Other triangulated data sources included field notes of observations during the interviews, a reflexive journal, literature and previous research on body neutrality, and a demographic survey. In this way, the constant comparative analysis unique to CGT increases rigor through complex coding procedures more so than other methods of qualitative data analysis (Hays & McKibben, 2021). The constant comparative analysis examines nuanced relationships between participants through negative case analysis to strengthen findings (Hays & McKibben, 2021).

Three-cycle coding and constant comparative analysis drove the data analysis process (Charmaz, 2014). Through the data analysis process, I constantly compared data (Mills et al., 2006). Inductive in nature, the constant comparison through the data analysis grounded my theories from the participants’ experiences (Mills et al., 2006). In alignment with CGT, I coded the interviews through a fluid process of initial coding, focused coding, and theoretical coding. During initial coding, I focused on “fragments of data,” such as words, lines, segments, and incidents (Charmaz, 2014, p. 109). The initial coding process not only included the transcripts, but also continued the interaction and data collection to facilitate the continuous analytical process. I also engaged with focus coding, wherein I used the most significant and frequent codes that made the most analytic sense (Charmaz, 2014). The focused codes were more theoretical than line-by-line coding practices. I engaged in theoretical coding of the data; theoretical coding is a way of “weaving the fractured story back together” (Charmaz, 2014, p. 63). In accordance with Charmaz (2014), theoretical coding involved clarifying the “general context and specific conditions” and discovering “participants’ strategies for dealing with them” (p. 63). As I moved throughout the three-cycle coding process, the number of codes, categories, and emerging core categories decreased and refined, leaving me with the final core categories described below (Khanal, 2018).

Rigor and Trustworthiness
     Throughout the totality of the research process, I engaged with five strategies to ensure trustworthiness. In the data analysis process, significant care was taken to ground analytic claims in the data obtained and remain true to the raw material provided by participants (Charmaz, 2014). I fostered trustworthiness through member checking and memo-writing (Creswell & Poth, 2017). I sent the transcript and the themes to participants and had six of 10 participants verify the themes as being congruent with their experiences. The other participants did not respond to the email with the transcript. Memo-writing was critical in constructing theoretical categories (Charmaz, 2014). I stopped and analyzed my ideas about the codes and emerging categories via memo-writing. Successive memos kept me immersed in the analysis and increased the abstraction of my ideas (Charmaz, 2014). In the theory construction, I also triangulated data sources, including semi-structured interviews, field notes of observations during the interviews, memo-writing, literature and previous research on body neutrality, and a demographic survey. Charmaz (2014) emphasized the importance of “thick descriptions” (p. 14), which I captured via writing extensive field notes of observations during the interviews and compiling detailed narratives from transcribed tapes of interviews.

I also shared my memos and data analysis process with an external auditor (Hays & McKibben, 2021). The external auditor was a researcher with experience in qualitative research and content familiarity. After the external auditor reviewed the data analysis trail, including the three stages of coding, I reviewed her written feedback and we met to process the feedback. The external auditor offered several pieces of feedback regarding the analytic process, including leaning more into the theory rather than the stories and removing quotes that captured pieces outside of the theory (i.e., removing content rooted in diet culture and body positivity). Feedback was integrated to strengthen the study’s development and explication of the theory based on data.


This study involved the caregivers and researcher co-constructing the parenting theory while integrating body neutrality concepts. The theory stemmed from the perspectives shared by caregivers who parent in such a way as to promote body acceptance, such as focusing on what our bodies can do for us, avoiding body talk, eating the foods we want to eat, listening to our bodies, not focusing compliments on appearance, etc. As such, the grounded theory below explains caregivers interacting and experiencing body neutral parenting (Charmaz, 2014).

The emergent core category was the balancing of internal experiences with external parenting, moving toward body neutral parenting. The emergent core category captured the essence of the theory—parents integrating body neutrality balance internal experiences (e.g., their own relationship with their bodies and food) with external parenting (e.g., their parenting skills of how to handle food in the household). Figure 1 depicts a conceptual diagram of the body neutral parenting grounded theory. The “mobile” emphasizes the movement and interconnectedness within the body neutral parenting process. At the top of the diagram, there is a seesaw balance between the external parenting skills and internal experiences, processing, and regulating. The internal and external experiences teeter and totter and inform one another as a parent integrates body neutrality. The mobile diagram showcases that if one piece moves, the other pieces move as well. To illustrate, if a parent’s external parenting skills move (e.g., a parent no longer says negative things about their body in front of their children), their internal experiences are impacted (e.g., their own unmet childhood mental health needs related to body image are addressed). The core category of balancing internal experiences with external parenting moving toward body neutral parenting included two categories: (a) De-moralizing Food, Bodies, and Movement, and (b) Reprogramming and Re-Parenting. Each of the two emergent categories has associated subcategories.

De-moralizing Food, Bodies, and Movement
     The first category is De-moralizing Food, Bodies, and Movement (n = 10). Within this category, there were three subcategories: De-moralizing Food, De-moralizing Bodies, and De-moralizing Movement. The category embodied acknowledging and countering the large cultural narrative of “good” foods and “bad” foods as well as “good” bodies and “bad” bodies. Participants emphasized the impact of removing the reward and punishment that accompanies the moralization of food, bodies, and movement. As captured by Kimberly, body neutral parenting is about “giving children more of a voice”and trusting them: “When they say that they’re hurt, believing them; when they say that they’re hungry, believing them. Letting them speak for themselves and not speaking for them or for their body. Trusting that they know their body the best.” 

Figure 1

Note. This figure showcases the diagram of the body neutral parenting theory. The diagram shows a visual representation of the emergent core category, two categories, and six subcategories and their relationships (Charmaz, 2014).

De-moralizing Food
     The first subcategory (n = 10) was De-moralizing Food. Participants consistently noted that food was “one of the biggest” parts of body neutral parenting—specifically, approaching food not as “good” or “bad,” not as “healthy” or “unhealthy,” but simply, neutrally, as “fuel” for the body. Cassie articulated that “A big piece is trying to take the moral piece out of it too. That it’s somehow good to have a certain body or foods are good or bad. Just trying to get away from that.”

The demoralization of food, moving toward neutrality with food, presented in numerous ways across participants’ approaches to caregiving. A primary way in which participants showcased their beliefs about food with regard to body neutrality was to present different foods in a neutral way. For example, the neutral presentation of different foods could look like desserts on the child’s plate from the beginning of the meal, rather than something to be “earned” after eating the “good” foods first. Esmeralda articulated a way in which she demoralized foods and presented them neutrally through what she coined as “Tasting Tuesdays.” She shared:

Instead of making a meal that you serve up in bowls or on plates, you basically charcuterie board the whole meal. . . . I noticed the effect it had on my kids to present a bunch of options, including desserts or traditional treats—it was all presented together. I was laying out all the foods on equal ground, lots of options. And many traditionally unhealthy foods and many traditionally healthy foods just all on the table together. There was no instruction. They just got an empty plate, and they could fill it with whatever they wanted, and I think for them there was some autonomy built into that. They could decide exactly what and how much they wanted to eat off the table. But it also, I think, inspired some adventurousness in them.

Presenting foods neutrally mitigated food judgment, created variety and exposures to food, and met the developmental needs of her children by making mealtime fun.

Another pivotal element of de-moralizing food and moving toward neutrality with food was to create space for children to practice noticing their hunger and fullness cues. Jennifer shared about her experience helping her child learn to trust their body and its cues. She explained:

Trying to trust him and listening to his body, even though he’s 2, and knowing where to intervene and where I shouldn’t intervene. If I make dinner and I put it in front of him and he touches nothing and wants to get down, the way that I was raised was you finish your plate no matter what. Reading everything that I’m reading and trying to move to this neutral space. What I want to say is “At least taste it. At least take a bite. Take one bite. Take three bites.” And what I’m choosing to do is, “Okay, you don’t have to eat right now. We’ll have a bedtime snack later.” I was conditioned to think that first thought.

While not explicitly using the language, participants spoke to helping their children with their hunger, fullness, and satiety cues. Practicing satiety looked like the children being able to say, as Scarlett’s son said, “My body is hungry for ice cream.” Also, Kimberly shared trying to instill autonomy within her children as they learn their hunger, fullness, and satiety cues:

We do defer to them a lot in terms of what they eat or when they’re eating. My daughter wanted canned cooked carrots for breakfast. It was like, well, okay, that’s not maybe socially typical, eating cooked carrots for breakfast. But if that’s what your body wants, go for it. . . . They asked her a question at school when she was graduating from preschool. What would you spend $1,000,000 on? A doughnut. So, it’s like, okay, we’re not going to demonize your doughnuts. You can have your doughnuts when you want your doughnuts.

Here, Kimberly also captured body neutral parenting’s emphasis on avoiding “healthy” vs. “unhealthy” food and other dichotomous language, stemming from diet culture.

Neutral beliefs and behaviors regarding food also manifest via portion sizes for children. Scarlett highlighted differences she noticed in how her family members wanted to portion food for her two sons: one in a larger body and one in a smaller body. She explained that her family members will “offer to my one son and not to the other” while also saying “Oh, do you need that?” to the son in a larger body. Thus, integrating body neutral parenting entails presenting food neutrally, rather than being driven by internalized societal messages about food and thin privilege (e.g., suggesting to a child in a larger body that they may not need the amount of food they are being served perhaps because of anti-fat bias). Body neutral parenting applies for children of all body types.

Moreover, caregivers practicing body neutrality with their children talked about food in a way that emphasizes how it “fuels the body” rather than being about “reward or punishment.” Esmeralda explained:

It’s like you have to basically find a whole new system of rewards. Sweet things are good motivators. They’re reward systems. And they’re also seen as the desirable food after you choke down the “healthy” food . . . these are the “good” foods you have to eat in order to get the “bad” foods that you get rewarded with after dinner. That just is such an insidious concept.

Counter to food being a “reward” or “punishment,” children get to choose rather than falling into the power struggle with food. Cassie described

taking the power out of the food situation. With little kids, everyone thinks like, “Oh, you have to control it and you have to make sure they get vegetables in and all that stuff.” Then it becomes about this power dynamic and just trying to take power out of it and then it is about letting them listen to their body and learn about their body.

Avoiding using food as a reward or as a punishment was integral to the body neutral parenting approach.

De-moralizing Bodies
     The second subcategory (n = 9) was De-moralizing Bodies, wherein there are not “good” bodies and “bad” bodies. Leilani described, “In relation to size, shape, behavior, disposition, bad habits . . . everybody’s different.” Body neutral parenting conceptualizes bodies in neutral ways, emphasizing what they help people do. As Cassie explained, “You need food to do the things you want to do, and so we take care of our bodies . . . not to look pretty, but to be able to do—focus more on the doing.” Similarly, Leilani shared,

My go-to approach is to say things like “Everyone’s body is growing at its own pace” and “We have to let our bodies grow at their own pace.” I’m freaked out by stats on how many U.S. girls are dieting around age 10-ish. I’m hoping that my emphasis on letting our bodies do what they need to do will have some impact against pre-teen dieting fads taking hold in our home.

     Many participants spoke about their goal for their children of “listening to their bodies.” Kimberly explained, “We tell our children a lot, ‘Listen to your body.’ So, what your body is feeling, what your body is saying, if your body is not hungry anymore, that’s fine. Or if it is hungry.” Further, participants named the impact of modeling, and not modeling, ideals about bodies. To illustrate, Imani explained,

Not talking about other people, that is a huge thing in our family, is just to not talk negatively about people that we don’t know or about people we do know. We don’t talk negatively about our own bodies in front of our kids or anybody else’s body in front of our kids. That’s honestly probably one of the more impactful things that we do.

Kimberly, too, emphasized being mindful of modeling how to think and talk about bodies:

Making sure that we model kindness to our bodies in front of them as well. So not saying things that are self-deprecating about the way that we look. Making sure that our children don’t hear us saying, “Oh my gosh, I’m just so fat,” those kinds of messages.

Also, participants emphasized integrating body neutrality into clothing approaches with their children. Scarlett described being mindful of the language she uses regarding clothes and bodies: “You’re too big for that versus those clothes don’t fit your body, or you’re too small for that versus that doesn’t really look like it’s comfortable on your body. Let’s find something that works best for you.”

De-moralizing Movement
     The last subcategory (n = 7) was De-moralizing Movement, which included engaging in movement for fun and being mindful of how we speak about exercise. Imani explained:

And so I think that for us, we really try to keep those things [exercise, body image, and food] disconnected. If you’re doing gymnastics, it’s because you’re interested in it and you think it’s a fun thing, not because it’s going to impact your body, not because you know it’s going to make you thin. It’s because you think it’s fun.

Cassie conceptualized movement as being fun, not for compensation, as well: “Being excited about things our bodies are doing and not just kind of the emphasis on like, well, if it’s fun, let’s do it. But if it’s not fun, then we’re not going to push ourselves or torture ourselves.” Moreover, Scarlett emphasized the importance of being conscientious of language used to describe her children’s bodies:

How big they are. We use that term especially with male children. But you are such a big boy is always the thing. You’re such a big boy . . . instead trying to just say things like, “Oh, hey, that’s really awesome that you can do X, Y, and Z.” Trying to make it very concrete, it’s very cool that your body allows you to run around and play.

     When it came to De-moralizing Food, Bodies, and Movement, a theme of removing the “shoulds” prevailed across participants. Kimberly described trying to “stay neutral with foods so that we don’t end up so much down the should line of what they should be eating or what they should be doing in terms of physical activity or those kinds of things.” Taking out the “should” entailed avoiding dictating what children “should be eating, “should look like,” or how they “should be exercising.” In summary, as poignantly articulated by Logan, “just focusing on the objectivity of what’s there without having the positive or negative associations.”

Reprogramming and Re-Parenting
     The second category (n = 10) was Reprogramming and Re-Parenting. Beyond the skills of body neutral parenting, a key tenet of the approach was ample self-reflection. Caregivers engaged in deep reflection of their own relationship with food, their body, and movement while supporting their children in their body image development. The self-reflection process entailed identifying, rewiring, and, often, re-parenting oneself through the sociocultural messages that have permeated one’s life span. Scarlett shared that body neutral parenting “makes me reflect on myself and why I’m saying the things I’m saying and why I feel the way I’m feeling.” Subcategories of Reprogramming and Re-Parenting included: Knowing Your Why, Being Gentle With Yourself, and Needing Support.

To illustrate, Leilani increased her awareness of her history with disordered eating and exercising for compensation and shared the impact her daughter has had on rewiring her way of thinking:

If I had a child who was very thin, it would have reinforced that dysfunction for me, because then I’m someone who produced a very thin child, and that makes me even better. . . . And then when you have a kid who’s really big and she’s pretty chubby, that you have to make such a hard shift to undo. Being the skinniest person in the room isn’t your greatest value in life and really reestablishing that personal value system. That’s been a massive kind of change for me.

This is a tangible example of the rewiring that happened for Leilani, though all of the parents spoke to their rewiring process and need to re-parent themselves alongside their children.

Knowing Your Why
     The first subcategory (n = 10) of Reprogramming and Re-Parenting was Knowing Your Why. Participants acknowledged the value they put into the parenting approach. Jennifer captured common collective values of body neutral parenting when she shared:

Number one, reducing shame. Number two, increasing quality of life and self-confidence . . . that would probably eventually help with any mental health issues or any relationship issues because he’ll have the self-confidence to say where his boundaries are and trust his body. And at the same time listen to other people and be empathetic.

Similarly, Kimberly emphasized how much it means to be parenting without shame: “I love that we know we’re not parenting with shame . . . as the hidden motivator. That’s why you don’t eat that extra food you might be hungry for.”

A significant challenge for many participants was the “internalized messaging” they experienced regarding their body image, food, and movement. Almost all of the participants (n = 8) directly spoke to their experiences with an eating disorder or disordered eating driving their desire to parent from a body neutral stance. Cassie, for example, cited her eating disorder recovery as sparking her passion for body neutral parenting:

Right when my husband and I got married, I went into treatment for an eating disorder, and so that shaped me a lot. . . . I was using all of the things that I had learned and trying to really instill it in them. How we talk about food, how we talk about bodies. It was such an integral part of my parenting.

Being Gentle With Yourself
     The second subcategory was Being Gentle With Yourself. Each participant (n = 10) criticized themselves in some fashion about not perfectly integrating body neutrality into their parenting approach. They were quick to highlight their failures and slow to honor their successes. Body neutral parenting, given its emphasis on countering long-standing sociocultural messaging, requires offering oneself a great deal of grace. Body neutral parenting entails tremendous learning, and that learning starts with reminding caregivers that they are doing the best that they can with the knowledge, support, and resources that they have. Imani spoke to how she navigated thoughts from these internalized messages and filtered them:

I think about things like, “She’s thinning out.” . . . It’s so ingrained, it’s hard not to think those things. And so then even if that’s something that goes across my mind or I think about the things that they’re eating and how that might impact their body or their physical health, just stopping that conversation with me and not actually talking about that with them, it’s not something that they need to hear. So, I think that it’s just as much what we don’t say as much as what we do say to them.

     Having thoughts stemming from diet culture and stumbling and saying the “wrong” thing is inevitable when rewiring these deeply embedded messages. Not only are those moments of “messing up” normal, but they also create space for beautiful moments to repair. Scarlett explained her process of repairing the inevitable ruptures:

Which all sounds well and good and wonderful until you are running around with a 4-year-old and a 5-year-old on your day to day. I will also balance that, it’s also trying to catch myself when I say things that I’ve just internalized from society in my own childhood and being like, “Hey, isn’t that interesting.” Just talking out loud to them. Saying, “Isn’t it interesting that I said X, Y, and Z? Is that really maybe the best way to talk about our bodies?” Trying to just be reflective and knowing that I’m not always going to be body neutral but trying to be intentional about noticing when I’m not.

The participants reflected that parenting is an imperfect, human process.

Needing Support
     The third subcategory was Needing Support. All of the caregivers in the study (n = 10) spoke to the importance of feeling support in their parenting approach. Support looked different for each family; some received support through social media, and others described finding support from their partner or other like-minded caregivers. Every participant described the role that social media had in their body neutral parenting approach. Many described learning about the approach via social media and experiencing continued support through certain social media pages. For example, common social media pages referenced by participants included Feeding Littles, Our Mama Village, Dr. Becky, and Kids Eat in Color. Most participants recommended that caregivers interested in starting body neutral parenting seek out social media for knowledge and support.

Additionally, participants emphasized the importance of being on the same page with other primary caregivers. Consistently, participants accentuated the need to talk through how to navigate situations in advance, to be on the same page for how to handle them. To illustrate, Scarlett described how to navigate their child “wanting ice cream after not eating all of their dinner” and how she and her partner talked through how to approach that situation. Esmeralda emphasized a need for support that she felt she was not getting:

I don’t think I’ve really found a group of parents or moms where we can talk through these things or troubleshoot together. I feel like I’m a consumer of some social media on the topic, and then I’m just sort of alone.

Feeling supported appeared to be integral to body neutral parenting.


This co-created grounded theory on body neutral parenting is a valuable addition to the literature, given the gaps in understanding how counselors can help guardians support healthy body image amongst children (Klassen, 2017). Given the significant familial influence on body image development, counselors can consider this study’s findings through a preventative lens (Liechty et al., 2016). The findings align with the scant literature on body neutrality, suggesting the need for continued exploration of how to support children, adolescents, and their families in their conceptualizations of body, food, and movement (Gutin, 2021). Mental health counselors can consider body neutral parenting as an avenue to foster positive familial influence in body image development. Positive familial influence on body image and related self-worth can prevent disordered eating, negative body image, and low self-worth (Veldhuis et al., 2020). Thus, body neutral parenting appears to have the potential to have significant impact on the mental health and self-efficacy of children, as well as their caregivers.

Based on the findings of this study, critical tenets of body neutral parenting include de-moralizing food, bodies, and movement, and reprogramming and re-parenting. The co-created parenting theory constructed in this study can be utilized as a way of conceptualizing a parenting practice that facilitates healthy body image development for families. Specifically, counselors can help families learn that food is not “healthy” or “unhealthy” and there are not “good” or “bad” bodies. In addition, the co-created theory emphasizes the need for counselors to help family members heal from internalized messages and misconceptions about health that can perpetuate body image dissatisfaction and disordered eating across generations.

Implications for Counselors and Caregivers
     Counselors and caregivers are uniquely positioned to use the findings of this study to inform how they support children and their body image development. In this study, parents offered their approach to integrating body neutral parenting with their children. The co-created theory of body neutral parenting offers a baseline for counselors and parents to consider, and future research on the theory is needed. Thus, counselors and parents can consider learning about body neutrality and integrating the principles in supporting the mental health of families.

     Body neutral parenting gives families and counselors alike a framework of how to navigate conversations of body, food, and movement to promote a healthy relationship with body image. Families need the language, including specific scripts of what to say and do, and what to avoid saying and doing, to support their children in their body image development. It appears that many families would be interested in shifting the larger sociocultural narrative, including diet culture, with their approach to raising their children, if they had the appropriate psychoeducation and support (Siegel et al., 2021). Clinical mental health counselors can meet that need. The co-created grounded theory in this study and further research can provide a launching pad for counselors who want to take a more preventative approach to body image and related mental health support for youth. Counselors can teach families about de-moralizing food, bodies, and movement in their household, for example, as part of the counseling process for children and adolescents who are at risk for disordered eating and body image concerns.

Counselors can consider how to be of support to families with an interest in integrating body neutrality into their childrearing approach. Mental health professionals can consider how to be of support through the arduous, though meaningful, process of simultaneously parenting one’s children and re-parenting oneself. Some ways in which mental health counselors can support families include normalizing and validating how difficult body neutrality can be and offering specific scripts of what to avoid saying and what to say instead. To illustrate, a counselor might provide psychoeducation to a parent on how to talk to their child about food. Rather than saying “Apples are good for you,” the caregiver could say, “Red food gives you a strong heart” (Kids Eat in Color, 2022). Moreover, families will need support as they navigate the tremendous amount of rewiring involved for body neutral parenting. Counselors can keep in mind the larger overarching goal to drive their clinical decisions in supporting families through body neutral parenting and avoid the negative experience of shame (Ruckstaetter et al., 2017). Counselors can support families in realizing that parenting is an imperfect, human process. Reminding caregivers that imperfect moments will happen, and how to be gentle with themselves, is critical for caregivers continuing the body neutral lifestyle.

As practicing counselors, we must engage in deep reflective practice ourselves to support families and children with body neutrality. In order to be culturally responsive and meet the needs of diverse families, we must “gain knowledge, personal awareness, sensitivity, dispositions, and skills” specific to body neutrality (ACA, 2014, C.2.a). All people have internalized messages and “shoulds” about food, bodies, and exercise, and those internalized biases can hinder the counselor’s ability to support the intricate needs of diverse families healing their relationships with food, bodies, and exercise. Thus, it is an ethical imperative for counselors to engage in self-reflective work about their internalized messages and how those biases might impact the body image needs of children. To illustrate, a counselor might have thin privilege and internalized messages of fat phobia and unknowingly perpetuate the social justice issue of sizeism. Similarly, a parent might make negative comments about the larger body individuals on a TV show. When working with a client in a larger body, a counselor might congratulate the client on their weight loss, when the client might actually be struggling with restricting food and exercising for compensation. It remains an ethical and social justice requirement to engage in both self-reflective work and learning new skills, such as de-moralizing food, to be a culturally responsive, ethical counselor.

Parents and Caregivers
     Relatedly, parents and caregivers can consider body neutrality when supporting their children with their body image development. For example, parents might consider the findings of this study and consider what de-moralizing food, bodies, and movement might look like in their home as well as reflect on their own healing process related to reprogramming and re-parenting. Parents might first identify how they engage in power struggles with food; use food as a reward; or use moralized language around food, bodies, and movement. Then, they might work toward identified areas for growth that can help move toward a more neutral relationship with food, bodies, and movement in their home.

Parents might be intentional about their use of language related to food, bodies, and movement with their children. For example, parents might avoid using the terms “healthy” and “unhealthy” related to food, but rather, emphasize the nutrients in the food, how the body feels after food, and other concepts congruent with intuitive and mindful eating. Further, in this study, many parents prefer the term “movement” over “exercise,” as it more accurately captures the relationship with moving the body. “Exercise” has a connotation for many clients as being punitive, exhausting, or for compensation, as opposed to “movement” embodying the mindful moving of the body for fun concepts aligned with body neutrality. In addition to language considerations, parents might consider how they maneuver mealtimes and integrate suggestions from the findings of this study, such as offering sweet foods at the same time as the meal, rather than having the dessert afterward as something to be earned.

Parents might also engage in their own healing and reflective practices, such as identifying their own food rules and reprogramming their internalized messages about food. Parents can model body neutrality with their own body by avoiding negative body talk, such as “I am so fat” or “I am bad for eating that, now I need to walk off those calories,” and replacing those comments with more body neutral statements. Similarly, caregivers can be mindful of how they talk about others’ bodies, such as avoiding negative comments about the larger body individuals on a TV show. Examples of body neutral statements might be: “My body is hungry for” and “I love that my body allows me to give you big hugs.”

     The sampling procedure is a limitation of this study. Onwuegbuzie and Collins (2007) suggested an ideal sample size between 12 and 15 for a grounded theory investigation using interviews. Although the study met theoretical saturation, the sample size was slightly under some recommended sources for a grounded theory investigation with 10 interviews. Moreover, although attempts were made to have a diverse sample and a geographically diverse sample was acquired, the study primarily captured the experiences of highly educated, middle-class mothers.

In addition, another primary limitation is the self-report from parents. Although parents self-reported as enacting body neutral parenting practices, I did not confirm if their self-report aligned with their actual parenting practices. As such, this study was not able to confirm how or in what way the participants’ parenting was effective. Moreover, research has not yet confirmed that body neutral parenting practices are helpful for children, necessitating further outcome research.

Future Research
     Future studies could cast a more comprehensive, representative net and capture the experiences of other caregivers of more diverse gender, socioeconomic, and educational backgrounds. Researchers could explore the nuances of caregivers integrating body neutrality into their approach caring for their children, such as specific developmental considerations. Research exploring current counseling practices, including how counselors support families through body neutral parenting, would also be a helpful addition to a scant literature base.


This study uncovered body neutral practices that caregivers and mental health professionals alike can use to support the body image development of children and adolescents. In particular, findings emphasized the importance of the caregiver’s reflective work and de-moralizing food, bodies, and movement. Body neutrality as an approach to parenting appears to underpin the healthy development of body image and related self-esteem in children and adolescents.

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


Abraczinskas, M., Fisak, B., Jr., & Barnes, R. D. (2012). The relation between parental influence, body image, and eating behaviors in a nonclinical female sample. Body Image, 9(1), 93–100.

American Counseling Association. (2014). ACA code of ethics.

Charmaz, K. (2014). Constructing grounded theory: A practical guide through qualitative analysis (2nd ed.). SAGE.

Charmaz, K., & Liska Belgrave, L. (2012). Qualitative interviewing and grounded theory analysis. In J. F. Gubrium, J. A. Holstein, A. B. Marvasti, & K. D. McKinney (Eds.), The SAGE handbook of interview research: The complexity of the craft (2nd ed., pp. 347–365). SAGE.

Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and research design: Choosing among five approaches (5th ed.). SAGE.

Damiano, S. R., Gregg, K. J., Spiel, E. C., McLean, S. A., Wertheim, E. H., & Paxton, S. J. (2015). Relationships between body size attitudes and body image of 4-year-old boys and girls, and attitudes of their fathers and mothers. Journal of Eating Disorders, 3(1), 1–10.

Damiano, S. R., McLean, S. A., Nguyen, L., Yager, Z., & Paxton, S. J. (2020). Do we cause harm? Understanding the impact of research with young children about their body image. Body Image, 34, 59–66.

Dittmar, H., Halliwell, E., & Ive, S. (2006). Does Barbie make girls want to be thin? The effect of experimental exposure to images of dolls on the body image of 5- to 8-year-old girls. Developmental Psychology, 42(2), 283–292.

Gutin, I. (2021). Body mass index is just a number: Conflating riskiness and unhealthiness in discourse on body size. Sociology of Health & Illness, 43(6), 1437–1453.

Hays, D. G., & McKibben, W. B. (2021). Promoting rigorous research: Generalizability and qualitative research. Journal of Counseling & Development, 99(2), 178–188.

Herle, M., De Stavola, B., Hübel, C., Abdulkadir, M., Ferreira, D. S., Loos, R. J. F., Bryant-Waugh, R., Bulik, C. M., & Micali, N. (2020). A longitudinal study of eating behaviours in childhood and later eating disorder behaviours and diagnoses. The British Journal of Psychiatry, 216(2), 113–119.

Horton, E. (2023). “I want different for my child”: An interpretative phenomenological analysis of mothers’ histories of disordered eating and the impact on their parenting approach. The Family Journal, 31(2), 314–321.

Horton, E., & Powers, M. (2024). Demoralizing food, bodies, and movement: A phenomenological exploration of caregivers’ experience in a body neutral parenting support group. The Family Journal.

Khanal, K. P. (2018). Constructivist grounded theory practice in accountability research. Journal of Education and Research, 8(1), 61–88.

Kids Eat in Color []. (2022, April 21). How to talk: May not help, may help a lot [Photograph]. Instagram.

Klassen, S. (2017). Free to be: Developing a mindfulness-based eating disorder prevention program for preteens. Journal of Child and Adolescent Counseling, 3(2), 75–87.

Kluck, A. S. (2010). Family influence on disordered eating: The role of body image dissatisfaction. Body Image, 7(1), 8–14.

Liechty, J. M., Clarke, S., Birky, J. P., & Harrison, K. (2016). Perceptions of early body image socialization in families: Exploring knowledge, beliefs, and strategies among mothers of preschoolers. Body Image, 19, 68–78.

Mills, J., Bonner, A., & Francis, K. (2006). The development of constructivist grounded theory. International Journal of Qualitative Methods, 5(1), 25–35.

National Eating Disorders Association. (2022). Body image.

Neumark-Sztainer, D., Bauer, K. W., Friend, S., Hannan, P. J., Story, M., & Berge, J. M. (2010). Family weight talk and dieting: How much do they matter for body dissatisfaction and disordered eating behaviors in adolescent girls? Journal of Adolescent Health, 47(3), 270–276.

Onwuegbuzie, A. J., & Collins, K. M. T. (2007). A typology of mixed methods sampling designs in social science research. The Qualitative Report, 12(2), 281–316.

Patton, M. Q. (2014). Qualitative research and evaluation methods: Integrating theory and practice. SAGE.

Pellizzer, M. L., & Wade, T. D. (2023). Developing a definition of body neutrality and strategies for an intervention. Body Image, 46, 434–442.

Perry, M., Watson, L., Hayden, L., & Inwards-Breland, D. (2019). Using body neutrality to inform eating disorder management in a gender diverse world. Child and Adolescent Health, 3(9), 597–598.

Phares, V., Steinberg, A. R., & Thompson, J. K. (2004). Gender differences in peer and parental influences: Body image disturbance, self-worth, and psychological functioning in preadolescent children. Journal of Youth and Adolescence, 33(5), 421–429.

Pursey, K. M., Burrows, T. L., Barker, D., Hart, M., & Paxton, S. J. (2021). Disordered eating, body image concerns, and weight control behaviors in primary school aged children: A systematic review and meta-analysis of universal–selective prevention interventions. International Journal of Eating Disorders, 54(10), 1730–1765.

Ricciardelli, L. A., McCabe, M. P., & Banfield, S. (2000). Body image and body change methods in adolescent boys: Role of parents, friends and the media. Journal of Psychosomatic Research, 49(3), 189–197.

Rodgers, R., & Chabrol, H. (2009). Parental attitudes, body image disturbance and disordered eating amongst adolescents and young adults: A review. European Eating Disorders Review, 17(2), 137–151.

Ruckstaetter, J., Sells, J., Newmeyer, M. D., & Zink, D. (2017). Parental apologies, empathy, shame, guilt, and attachment: A path analysis. Journal of Counseling & Development, 95(4), 389–400.

Sharpe, H., Patalay, P., Choo, T.-H., Wall, M., Mason, S. M., Goldschmidt, A. B., & Neumark-Sztainer, D. (2018). Bidirectional associations between body dissatisfaction and depressive symptoms from adolescence through early adulthood. Development and Psychopathology, 30(4), 1447–1458.

Siegel, J. A., Ramseyer Winter, V., & Cook, M. (2021). “It really presents a struggle for females, especially my little girl”: Exploring fathers’ experiences discussing body image with their young daughters. Body Image, 36, 84–94.

Thompson, J. K., Heinberg, L. J., Altabe, M., & Tantleff-Dunn, S. (1999). Exacting beauty: Theory, assessment, and treatment of body image disturbance (1st ed.). American Psychological Association.

Veldhuis, J., Alleva, J. M., Bij de Vaate, A. J. D., Keijer, M., & Konijn, E. A. (2020). Me, my selfie, and I: The relations between selfie behaviors, body image, self-objectification, and self-esteem in young women. Psychology of Popular Media, 9(1), 3–13.

Walker, D. C., Gorrell, S., Hildebrandt, T., & Anderson, D. A. (2021). Consequences of repeated critical versus neutral body checking in women with high shape or weight concern. Behavior Therapy, 52(4), 830–846.

Wymer, B., Swartz, M. R., Boyd, L., Zankman, M., & Swisher, S. (2022). A content analysis of empirical parent engagement literature. Journal of Child and Adolescent Counseling, 8(1), 16–30.

Emily Horton, PhD, LPC, RPT, is an assistant professor at the University of Houston–Clear Lake. Correspondence may be addressed to Emily Horton, 2700 Bay Area Boulevard, Houston, TX 77058,

Abolitionist Praxis for Substance Use Clients Who Experience Anti-Drug Policing

Darius A. Green, Katharine R. Sperandio

Because of the long history of anti-drug policing in the United States and the criminalization of substance use, clients who use substances are vulnerable to direct and vicarious experiences of police violence. Consequently, those who use substances may face a greater risk of experiencing symptoms of trauma that counselors should address in treatment. We recommend the use of a trauma-informed and abolitionist praxis in clinical and social justice practices as a framework to support clients who use substances and have histories of exposure to police violence.
Keywords: substance use, police violence, trauma, abolitionist, social justice

     Policing in the United States has received increased scrutiny in recent years with renewed attention resulting from the Black Lives Matter protests in 2020. Specifically, policing has been critiqued by prison–industrial complex abolitionists—activists who advocate toward an end to systems of policing, prisons, and related carceral systems in favor of systems and practices that promote accountability, justice, healing, and transformation—as being inherently violent, meaning that it relies on the use of behavior that is considered violent in any context (Cullors, 2019; A. Y. Davis et al., 2022; Green, 2022; Kaba, 2021; Klukoff et al., 2021). Violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (Krug et al., 2002, p. 5). Thus, we define police violence as the inherently violent uses of force by police officers. According to the World Health Organization, there are four types of violence that can be used to categorize police violence: physical (e.g., arrests and the use of weapons), sexual (e.g., strip searching and sexual assault), psychological (e.g., intimidation and verbal threats), and neglect (e.g., failing to provide support to medical and mental health needs; DeVylder et al., 2017; Krug et al., 2002).

Current data suggests that 58.3 million U.S. residents over the age of 16 experienced contact from police officers in 2020 with roughly 1 million experiencing or being threatened with non-fatal force (Tapp & Davis, 2022). Moreover, of the 82 million arrests reported by the Federal Bureau of Investigation (FBI; 2022) between 2011 and 2021, substance use violations were the second most common arrests, accounting for 14% of arrests. Oftentimes, counselors may work with clients who have been court-ordered to treatment as part of diversion programs that seek to route individuals away from incarceration and toward treatment for criminalized behaviors, such as substance use (Scott, 2020). Given that substance use–related offenses are among the most common offenses leading to violence through an arrest (FBI, 2022), it is essential for substance use counselors to prepare to address experiences of police violence that may result from anti-drug policing—the use of police violence as a response to individuals who use substances. Although anti-drug policing impacts both those who use substances and those who traffic them, our discussion on anti-drug policing will focus on populations who use substances.

Research on counselor preparation suggests that most counselors receive no training regarding clinical practice and advocacy to address matters of police violence despite a recent study that found that 68.2% of counselors reported working with clients who had experienced police violence (Green & Evans, 2021). Moreover, Bride et al. (2009) found that most substance use counselors do not learn about treating psychological trauma in their academic programs and instead predominantly rely on continuing education. Given the vulnerable nature of those who use substances and evidence suggesting that gaps exist in training counselors in treating police violence and trauma, we will explore approaches to clinical practice, social justice, and advocacy to best support substance use clients who experience police violence because of anti-drug policing. Specifically, the purpose of this article is to provide a sociopolitical analysis of anti-drug policing in the United States that informs our proposal for substance use counselors to adopt and integrate an abolitionist praxis into their practice of counseling with clients who use substances.

Sociopolitical Context of Anti-Drug Policing in the United States

Initiated by President Richard Nixon in 1971 and escalated by President Ronald Reagan in 1982, the war on drugs increased and incentivized anti-drug policing and enforcement, intensified legal penalties associated with drug-related crimes, and demonized individuals, particularly those who were part of marginalized communities and struggled with substance use disorders (Benson et al., 1995; Cooper, 2015; Koram, 2022; Park et al., 2019). Cooper (2015) and Saleem (1997) noted that contemporary anti-drug policing practices, such as stop-and-frisk and police drug raids, have been permitted through court cases such as Terry v. Ohio, Whren v. United States, and Illinois v. Wardlow and have eroded the Fourth Amendment and 1878 Posse Comitatus Act protections against unreasonable searches, seizures, and militarization of policing. Specifically, these court cases have permitted frisking for reasonable suspicion, allowed police to conduct stops in which police may stop individuals for suspicion of drugs under the pretext of other minor criminalized violations, and expanded the definition of suspicious behavior that may warrant being stopped by police (Cooper, 2015; Saleem, 1997). Although several anti-drug policing reforms have been made, such as the development of drug courts and the decriminalization of substances in various states (Klukoff et al., 2021; Scott, 2020), anti-drug policing practices have persisted, expanded, and received legislative support. For example, despite stop-and-frisk searches being declared unconstitutional in 2013 with the decision in Ligon v. City of New York, the practice was reduced by 98% by 2017 as opposed to ceasing entirely (New York Civil Liberties Union, n.d., 2019). Despite this decrease, racial disparities were maintained in these stop-and-frisk practices between 2014 and 2017, as 53% of targets were Black and 28% were Latino (New York Civil Liberties Union, 2019). Lastly, President Donald Trump voiced support for greater anti-drug policing efforts, while President Joseph Biden’s Safer America Plan seeks reform that simultaneously increases funding for policing and substance use treatment resources (Kaba & Ritchie, 2022; Koram, 2022; The White House, 2022). Although these systemic supports for reform from the executive branch may be aimed at drug trafficking, individuals who use substances may be at continued risk of being impacted by anti-drug policing with the increased support for and reliance on carceral approaches.

Although reforms related to criminalized behaviors may reduce harm through their trauma-informed focus, abolitionist authors and activists have critiqued such reforms as counter-productive when they expand the power and legitimacy of policing, maintain the criminalization of substance use, and perpetuate harm and violence toward those who use substances (Klukoff et al., 2021; Purnell, 2021a). For example, according to Fazel et al. (2017), 24% of the global imprisoned population meets the criteria for alcohol use disorder, compared to the less than 2% of the general population (Global Burden of Disease Network, 2016). Similarly, 30% of male prisoners and 51% of female prisoners meet the criteria for illicit drug use disorder, while less than 1% of the global population meets the criteria (Global Burden of Disease Network, 2016). Moreover, as stated earlier, substance use violations are the second most common arrest reason in the United States (FBI, 2022). Lastly, some authors have concluded that mixed results exist on the effectiveness of diversion programs for offenses associated with mental illness and substance use regarding recidivism and subsequent arrests (Klukoff et al., 2021; Scott, 2020). These data highlight a prevalent connection between policing, incarceration, and substance use in the United States and around the world despite contemporary reforms to anti-drug policing established through the war on drugs.

Policing functions to maintain social order and provide security by enforcing laws, policies, and social norms (Bureau of Justice Statistics, 2021; Giovengo, 2016). Moreover, police are ordained to investigate, arrest, and enact force upon those deemed as, or suspected to be, threatening to the safety and interests of dominant communities. Thus, the criminalization of substance use has been conceptualized as exerting control over and oppressing minoritized groups (Dollar, 2019; Purnell, 2021b). Marginalized communities have been hit especially hard by these zero tolerance policies, which drastically increased community members’ run-ins with police (Cooper, 2015). For example, the influx of stop-and-frisk procedures, a method that permitted police officers to detain an individual suspected of illegal activity and physically search them, led to minoritized individuals being racially profiled and targeted for searches without specific cause (Cooper, 2015). In fact, anti-drug policing has resulted in a shift from Black people accounting for 22% of those arrested in 1976 to 40% in 1992, despite making up 12% of the U.S. population (Cooper, 2015; Tonry, 1994). Thus, instead of eliminating substance use in communities, these crackdowns have only further increased the prevalence of police brutality, traumatized communities and individuals, and increased violence within communities (Cooper, 2015; Rhodes et al., 2006; Werb et al., 2011).

Structural Violence and Trauma From Anti-Drug Policing

Given the confiscation of an individual’s bodily autonomy, resulting in the infringement of the individual’s basic and constitutional rights and liberties, as well as the possibility for physical harm to take place during searches, anti-drug policing, which can involve violence, harassment, and killings, can place significant psychological stress and turmoil on targeted individuals (Park et al., 2019; Sarang et al., 2010). It is essential to analyze the long-term consequences of police violence perpetuated upon impacted individuals, including the possibility of traumatization and death (Bryant-Davis et al., 2017; Cooper, 2015; Krieger et al., 2015). Emerging research has demonstrated connections between being stopped by police and symptoms of anxiety and post-traumatic stress disorder (PTSD), particularly when the experience is perceived as intrusive and unjustified (Geller et al., 2014); suicide attempts (DeVylder et al., 2017); and symptoms of manic and depressive episodes (Meade et al., 2017). Likewise, vicarious traumatization from watching or learning of another individual experiencing police violence is also a concern given the high proportion of individuals living with substance use disorders who have both experienced trauma and witnessed police violence (El-Bassel et al., 2011; Park et al., 2019; Shaw et al., 2016). Research on those who witness police violence has often emphasized the unique impact on Black people. This research has demonstrated associations with vicarious exposure and poor mental health (Bor et al., 2018), distress from anticipated exposure following media consumption (Green et al., 2024), and psychological distress among Black mothers (Joe et al., 2019). Galovski et al. (2016) demonstrated that community protests following instances of police violence may result in symptoms of depression and PTSD among community members. Additionally, recent research has demonstrated a connection between vicarious exposure and increased cannabis use among Black Americans (Motley et al., 2022). Taken together, these findings suggest that directly and vicariously experiencing police violence may promote greater risk of traumatization.

Literature suggests that these encounters with police may end in violence beyond psychological distress because of the influence of stigmatization and prejudice against people who use substances (Cooper et al., 2005; Hayashi et al., 2013; Lunze et al., 2015; Wood et al., 2017). Officers may also confiscate civilians’ syringes during stop-and-frisk encounters, increasing the prevalence of syringe sharing, a known risk factor for HIV and HCV transmission (Beletsky et al., 2010; Park et al., 2019; Small et al., 2007). Detainment for substance use is also associated with increased risk of death following release because of withdrawal and increased risk of overdose (Chang et al., 2015; Fazel et al., 2017; Kinner et al., 2012; Pratt et al., 2010). Stress and traumatization experienced from anti-drug policing is also associated with high-risk behaviors, including drug injection, among addicted individuals (Maher, 2004; Shannon et al., 2008; Volkmann et al., 2011). Moreover, in one study, individuals needing treatment for substance use disorders were 2.74 times more likely to experience arrest and physical assault from police (Werb et al., 2016). Additionally, Werb et al. (2016) found that 27.5% of police encounters occurred within 500 meters of a substance use treatment facility. Similarly, Park et al. (2019) found in a sample of people who inject drugs in Baltimore that 7% experienced physical police violence and one in four knew someone else who had experienced physical police violence, fueling a deep mistrust of the system. Fear of potential retaliation by the police may also discourage individuals, particularly those with marginalized identities, from going to the police during a crisis or emergency situation, such as in cases of overdose. This mistrust of the system negatively impacts individuals’ willingness to pursue treatment services, especially when they are in fear of being detained or harmed by police officers (Alang et al., 2017; Cooper, 2015; Park et al., 2019). For example, a qualitative study described the impact of increased surveillance from police as both threatening and interfering with harm reduction practices (Cooper et al., 2005). Treatment centers are typically more centralized in areas where there is a higher drug activity which means that, because policing has a significant presence in these parts of communities, individuals may be hesitant to seek out help and support to avoid police encounters, negatively impacting social and health outcomes (Werb et al., 2016). Additionally, these crackdowns are associated with reductions in syringe exchange programs, drug treatment, and HIV testing accessibility (C. S. Davis et al., 2005; Park et al., 2019; Ti et al., 2013). These findings highlight how anti-drug policing actively inhibits access to safe and needed care.

A Case for Abolition in Substance Use Counseling

Because of the increased risk of experiencing police violence and the subsequent risk for traumatization from police violence, it is essential for counselors to address encounters stemming from anti-drug policing in treatment and develop practices that divest from policing practices and systems. Trauma-informed practice is a “fundamental obligation” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014, p. 5) for counselors who work with clients at the intersections of substance use and police violence to reduce or mitigate the adverse impacts of trauma on individuals’ physical, emotional, psychological, and spiritual well-being and to prevent further systemic (re)traumatization. Trauma-informed practice is that which recognizes and understands the impact and salience of trauma, effectively responding to it in ways that do not retraumatize and further perpetuate traumatic stress while also recognizing that marginalized groups are at greater risk of experiencing trauma and its effects (SAMHSA, 2014; Sweeney & Taggart, 2018). There are four assumptions that ground trauma-informed practices (adapted from SAMHSA, 2014): 1) a realization of the potentially long-lasting effects of trauma on individuals, communities, groups, families, and systems and that trauma can be perpetuated by systems like the criminal legal system, resulting in a significant impact on continued substance use and mental health; 2) the importance of recognizing the signs of trauma and refraining from pathologizing these responses; 3) the crucial need for a system or organization to respond supportively by applying the six principles of a trauma-informed approach; and 4) resisting the potential to retraumatize individuals who are accessing supports and care. Moreover, SAMHSA (2014) identified six principles of trauma-informed practices that are intended to serve as the fundamental spirit of trauma-informed care: 1) safety; 2) trustworthiness and transparency; 3) peer support; 4) collaboration and mutuality; 5) empowerment, voice, and choice; and 6) cultural, historical, and gender issues.

By SAMHSA’s description, current substance use treatment falls short of being trauma-informed when it occurs under systemic conditions in which anti-drug policing and police violence are part of the historical and current response in the treatment and care of individuals who struggle with substance use. As outlined above, anti-drug policing practices can result in police violence that includes stop-and-frisk, arrests, and an intimidating presence that may negatively interfere in treatment accessibility for individuals who are fearful of potential run-ins and harassment (Werb et al., 2016). Anti-drug policing and the broader criminalization of substance use may disrupt safety, retraumatize substance use clients, and diminish trust and transparency in accessing substance use treatment. Moreover, incarceration for using substances may inhibit the potential for peer support and collaborative approaches to treatment. Lastly, the existing racial disparities in anti-drug policing practices demonstrate a history of systemic racism that may disproportionately create a barrier to accessing trauma-informed care for racially marginalized groups, particularly Black Americans. Thus, we contend that an abolitionist praxis that opposes anti-drug policing and divests from carceral approaches to responding to individuals who use substances is needed to fully realize trauma-informed practice with clients who use substances.

Abolitionist Praxis for Substance Use Counseling

Abolition is a social justice praxis that is commonly referenced as a necessary solution to policing and its impact (A. Y. Davis et al., 2022; Kaba, 2021). Abolition refers to the broad movement of divesting from and eliminating carceral systems, such as law enforcement and prison systems, and carceral logics that seek to legitimize the use of punishment, retribution, and vengeance through carceral systems. Rooted in the efforts of Black feminist thought, advocacy, and organizing, abolition calls for a critical analysis of the ways in which policing has functioned to enact the violence of overlapping systems of oppression (Kaba & Ritchie, 2022). Kaba and Ritchie (2022) identified three objectives of abolitionist praxis. First, abolitionist praxis seeks to create collective safety from community violence and the violence of policing and related carceral systems that reinforce systems of oppression, such as White supremacy, patriarchy, and capitalism (Kaba, 2021; Kaba & Ritchie, 2022; Purnell, 2021a). Second, abolitionist praxis seeks to end violence from carceral systems through eliminating those systems as opposed to seeking reforms that preserve the inherent violence of policing and incarceration (Kaba & Ritchie, 2022; Klukoff et al., 2021). This second objective extends beyond institutions of policing and incarceration and extends to the ways in which carceral logic and behaviors of policing are embedded in other systems, institutions, and communities and often internalized by individuals (Kaba & Ritchie, 2022). Lastly, to achieve collective safety, abolitionist praxis necessitates a simultaneous transformation from reliance on the violence of policing and related carceral systems toward cultivating cultures, systems, communities, and ways of being that are centered around care, healing, justice, and accountability (Kaba & Ritchie, 2022).

Abolition exists beyond a theoretical and conceptual framework. It is an iterative process that combines theorizing, action, and reflection upon efforts that divest from and dismantle carceral systems and logics while simultaneously brainstorming solutions to community violence that promote safety, healing, and justice (Cullors, 2019; A. Y. Davis et al., 2022; Kaba & Ritchie, 2022; Klukoff et al., 2021). Abolitionist praxis often utilizes a transformative justice framework to achieve its objective of eliminating carceral systems while creating new systems and ways of being that foster safety, healing, and justice. Transformative justice aligns with abolitionist praxis in that it is a liberatory strategy that seeks to transform systems and structures that create the conditions for violence (Afuape & Kerry Oldham, 2022). While policing and incarceration focus on retributive justice that assigns inherently violent punishment as a mechanism for change regardless of the harm it causes, transformative justice through abolitionist praxis seeks to create processes of accountability for harm caused interpersonally from criminalized behaviors and systemically from policing and related carceral systems. As a result, abolitionist praxis utilizes transformative justice to create new systems, institutions, communities, strategies, and internalized ways of being that value safety, healing, and justice that are needed to cultivate trauma-informed care and practices for substance use clients.

Regarding substance use counseling, an abolitionist praxis seeks to reduce and eliminate violence as a response to substance use, decriminalize all substance use, and eliminate contact between substance use clients, police, and the broader criminal legal system. Similarly, an abolitionist praxis to substance use counseling challenges the logic that criminalization is a needed step in treatment for substance use. For example, in 2001, the Portuguese government enacted nationwide laws to decriminalize all substances, resulting in a decrease in the prevalence of drug use and overdose rates (Castelpietra et al., 2022; James et al., 2020; Pombo & da Costa, 2016; Smiley-McDonald et al., 2023). In 2021, Oregon decriminalized low-level drug possessions and subsequently increased options for substance use disorder treatment and harm reduction programs (Good et al., 2023; Smiley-McDonald et al., 2023). In their study, Smiley-McDonald et al. (2023) found that the Oregon legislation resulted in a decrease in the number of interactions between police officers and individuals who use drugs. Thus, the abolitionist goal of decriminalizing substance use while implementing harm reduction programs may function to both minimize inherently violent contact with police and reduce the prevalence of substance use.

Abolitionist praxis would also call for the development of accountability for interpersonal and community harm caused by client substance use that does not rely on legal punishment, or the threat of it, from the criminal legal system (Cullors, 2021). Accountability for harm caused under abolitionist theory entails a developed recognition of wrongdoing and harm, both interpersonally and as mediated by social, economic, and political context, and sustained effort toward intrapersonal, interpersonal, and institutional change that repairs harm (Cullors, 2021; Kaba, 2021). Counselors must re-envision both their clinical practice and engagement in advocacy toward abolition to holistically care for clients who use substances.

Clinical and Advocacy Recommendations

Given the previously outlined mental health outcomes that are associated with direct and vicarious experiences of police violence that suggest its traumatic impact (DeVylder et al., 2017; Galovski et al., 2016; Geller et al., 2014; Green et al., 2024; Joe et al., 2019; Meade et al., 2017; Motley et al., 2022), a trauma-informed approach is essential to working with those who experience police violence as a consequence of anti-drug policing. Counselors seeking to use a trauma-informed approach to treat substance use disorders must infuse abolition into their delivery of services while also engaging in advocacy beyond direct clinical work to better achieve SAMHSA’s six identified principles of trauma-informed practice. We provide an abolitionist framing of these six principles and offer abolitionist re-envisioning for substance use counseling below. Moreover, we adapted the sixth principle of cultural, historical, and gender issues to cultural competence and advocacy to emphasize the professional role of advocacy in counseling for substance use clients who experience anti-drug policing.

     Ensuring safety in the therapeutic space is essential because anti-drug policing and the threat of police violence pose a safety risk to clients who use substances and are involved in or at risk of being targeted by the legal system. One step toward maximizing safety for clients is to end the use of abstinence-based treatment. Given that counselors may serve as treatment referral sources for court-mandated clients who meet criteria for diversion programs that seek to route individuals toward treatment for substance use and away from incarceration (Scott, 2020), abstinence-based treatment needs critical examination. Although such interventions can reduce engagement in substance use and mental health symptoms (Pinals et al., 2019), they do so with a looming threat of police violence and incarceration as a consequence for failure to complete the requirements of the diversion program (Scott, 2020). This poses a value conflict with counselors who are treating court-mandated clients for substance use. Counselor participation in diversion programs may require disclosures of client participation and progress in counseling that may lead to legal consequences for clients if they do not meet requirements of the diversion program. For example, counselors may be ethically obligated to document client relapses, which are more common in substance use treatment for minoritized groups and those with histories of experiencing multiple traumatic events (Farley et al., 2004; Heffner et al., 2011), which may be requested by probation officers, attorneys, or courts. In such a scenario, disclosure of client progress in treatment could produce a risk of clients experiencing police violence and incarceration. Moreover, this may produce a circumstance in which a client’s dominant motive for engaging in treatment is to avoid the consequences of police violence and incarceration. Consequently, acknowledging the intrapersonal, interpersonal, and community impact of one’s substance use and engaging in accountability are likely to become secondary motives for change and repair of any harm caused. Although the potential for incarceration may serve as motivation for change for substance use clients, substance use counselors can align with an abolitionist praxis by engaging in theorizing to develop methods and systems that motivate client accountability and transformation without the threat of violence induced by carceral systems. Moreover, alignment with an abolitionist praxis may require substance use counselors to proactively use their power to advocate for harm reduction in treatment as alternatives to approaches that risk harm through police violence and incarceration. Harm reduction approaches emphasize safe use over non-use of substances and have demonstrated evidence of both maintained and reduced substance use, reductions in harm related to substance use (e.g., less police contact and fewer arrests and emergency hospital visits), and self-reports of feeling safer (Carrico et al., 2014; Smiley-McDonald et al., 2023; Vallance et al., 2016).

Anti-drug policing views substance use as threatening and seeks to foster security through violent force and criminalization (Kaba, 2021). This security comes at the expense of the safety and well-being of those who use substances. An abolitionist re-envisioning of safety is one that seeks to ensure safety from the harm that both substance use and carceral systems cause to individuals, families, and communities. Regarding safety for substance use clients who experience anti-drug policing, Drustrup et al. (2023) offered an abolitionist approach to safety planning that counselors can adapt to fit the needs of clients mandated to substance use treatment. This approach decenters the default reliance on police in crises and emergencies and emphasizes collaboration with clients to establish methods that can maintain safety. Adapting this to clients, counselors can minimize disclosures of substance use, especially to police, probation officers, and employees of the criminal legal system. Noting the importance of building networks of care in place of carceral systems (Drustrup et al., 2023; Kaba, 2021), counselors should simultaneously collaborate with clients to identify interpersonal and community mechanisms to maintain safety and progress toward substance use–related treatment goals, particularly for when relapses occur. Consequently, this also promotes safety from the impact of substance use and client empowerment, voice, and choice in their treatment and wellness. For example, counselors could simultaneously utilize family therapy as a mechanism to support structural change associated with the development of a client’s substance use and to promote accountability for harm caused by substance use within the family system. Furthermore, when harm from substance use extends to one’s community, in collaboration with clients and those directly impacted, counseling could be used to promote reparation for harm caused (Cullors, 2019). Counselors should be mindful of the possibility that clients may not readily share experiences of police violence and substance use because of distrust fostered by carceral systems and if they have experienced invalidation, blame, or neglect regarding their experiences of police violence. Thus, counselors can enhance safety, trust, and the potential for change with clients through a consistent practice of accurate empathy and attunement to clients’ subjective experience of police violence (Miller & Rollnick, 2013).

Trustworthiness and Transparency
     Trustworthiness and transparency are essential given the systemic distrust fostered by histories of collaboration between helping professions and carceral systems (Jacobs et al., 2021; Klukoff et al., 2021). Counselors need to promote an optimal level of safety and trustworthiness with their clients through nonjudgement, empathy, transparency, positive regard, validation, normalization of the client’s responses to adversity, and consistency (SAMHSA, 2014). Counselors pursuing abolition can establish trustworthiness and transparency through using the informed consent process to build rapport and establish parameters of the therapeutic relationship within a societal context that largely criminalizes substance use. While Drustrup et al. (2023) offered inspiration for abolition in the therapeutic relationship, counselors are ethically obligated to make exceptions to confidentiality when imminent risk to self and others is established. Additionally, as mentioned above, substance use counselors may be required to make exceptions to confidentiality to share progress for court-mandated clients. Informing clients of these exceptions to confidentiality is standard in helping professions; however, abolition can maximize trustworthiness and transparency by going beyond merely capturing client signatures on informed consent documents. In addition to establishing the limits of confidentiality, counselors pursuing abolition are recommended to ensure that clients fully understand these limits and the impact of these limits on their participation in the therapeutic context. For example, a substance use counselor could clearly articulate known risks of making exceptions to confidentiality of the therapeutic relationship with police and legal system employees, such as increased risk of experiencing police violence, incarceration, and state-sanctioned surveillance. Counselors pursuing abolition who are directly embedded in carceral systems as a function of their employment, such as prisons, should inform clients of any dual or conflicting interests associated with their counseling in the prison system. Additionally, counselors can use open-ended questioning to provide clients an opportunity to check their understanding of confidentiality, its limits, and the impact of needing to make exceptions to confidentiality. Moreover, counselors pursuing abolition should collaborate with clients to identify external resources to counseling that offer greater trustworthiness that can facilitate transformation and healing from substance use in situations where clients may feel a lack of trust in counseling because of the threat of carceral systems.

Peer Support
     Providing opportunities for peer support for clients who have experienced police violence and are living with substance use disorders could also be promotive and helpful for healing because of the access to other individuals who have undergone similar experiences. Group therapy has been associated with positive mental health outcomes, particularly among individuals with PTSD and substance use disorders, due to receiving mutual support from others who have similar experiences and can provide empathy, a sense of belongingness and collectivism, and the opportunity to provide and receive feedback; build safety through interpersonal relationships; and reduce feelings of isolation and loneliness (Barrera et al., 2013; Mott et al., 2013; Schwartze et al., 2019; Sloan et al., 2013). Substance use counselors pursuing abolition can actively incorporate group therapy within the therapeutic context and help clients heal following traumatization from police violence while promoting their long-term recovery. Additionally, counselors employed in treatment centers who are pursuing abolition should be mindful of added benefits toward safety and trustworthiness that embedding peer support can offer, particularly for court-mandated clients. When a client is unable to experience enough safety and trustworthiness because of the threat and impact of carceral systems, embedded peer support that exists outside of the counselor–client relationship can provide alternate spaces for clients to be heard and validated. Abolitionist substance use counselors can advocate for the inclusion of peer mentoring for accountability and transformation akin to that which exists within 12-step groups through sponsor relationships. Although it may be conceptualized as part of a process of accountability to utilize clients who have advanced in their treatment as peer mentors, counselors pursuing abolition should also consider the feasibility of paying peer mentors to avoid replicating the occurrence of unpaid and underpaid labor that may occur in prison systems.

Collaboration and Mutuality
     It is essential for counselors pursuing abolition to cultivate environments and therapeutic relationships that promote collaboration and mutuality. It would behoove substance use counselors to utilize frameworks for treatment that are inherently trauma-informed and collaborative, such as motivational interviewing, for assessing client motivation for change and structuring treatment with clients that is centered around partnership, acceptance, compassion, and evocation (Clark et al., 2014; Miller & Rollnick, 2013). These efforts may be particularly beneficial for clients who have experienced police violence as a result of anti-drug policing in that they allow greater client participation and trustworthiness to a client population that may be prone to experiencing coercion and restricted freedom and being acted upon. Abolitionist substance use counselors can foster greater collaboration and mutuality in their practice of counseling by making mutual aid foundational to their practice. Mutual aid is an intentional resistance to reliance on institutions that cause structural violence (S. W. Davis & Fayter, 2021; Jacobs et al., 2021). Instead of relying on such institutions, mutual aid seeks to establish networks of care that use community members and resources to meet the needs of others (S. W. Davis & Fayter, 2021; Jacobs et al., 2021). Establishing mutual aid in substance use counseling for clients who experience anti-drug policing requires counselors to advocate to establish and streamline connections to community resources that address underlying, unmet, or neglected needs of clients that play a role in their use of substances and experience of anti-drug policing. For example, an abolitionist substance use counselor may actively coordinate with community agencies that provide support in securing shelter to mitigate substance use and the risk of subsequent anti-drug policing that may be associated with homelessness. Integrating peer support and mentoring, as mentioned previously, within and outside of treatment facilities could function as mutual aid; however, substance use counselors working in carceral institutions may experience pushback to such efforts given that mutual aid seeks divestment from carceral systems (S. W. Davis & Fayter, 2021). Lastly, in terms of collaborative goal-setting, the counselor can work with the client to identify the client’s objectives for attending therapy. The counselor is recommended to honor the client’s voice and work with the client to establish whether the client would like to refrain from using substances in the future, engage in harm reduction practices, and/or process the trauma that the client may have experienced at the hands of police.

Empowerment, Voice, and Choice
     Anti-drug policing, incarceration, drug courts, and related carceral approaches to substance use may use interventions that limit the agency of those subjected to their demands. Counselors can engage in an abolitionist praxis that is rooted in trauma-informed practice by screening and assessing for the prevalence and impact of police violence as a potentially traumatic stressor that relates to the use of substances (Green, 2022; Green & Evans, 2021). Given the importance of divesting from carceral systems and logic in abolitionist praxis, counselors need to engage in an ongoing and iterative process of reflection and change in attitudes and practices that reinforce the criminalization of substance use and practices that treat it as the moral failure of the individual. This can be achieved through screening and assessment for substance use and police violence that counteracts experiences of shame and guilt that may be fostered from interactions with police and the criminal legal system (Clark et al., 2014). Moreover, abolitionist praxis in counseling with clients who experience police violence due to anti-drug policing requires a strength- and healing-oriented approach as an act of radical resistance to the pathologizing and moralizing norm of carceral approaches (Cook et al., 2014; Moh & Sperandio, 2022). In practice, this may entail an intentional focus on a client’s progress in collaboratively defined goals and support in actualizing accountability for harm caused from substance use. Similarly, this would require a commitment to approaching clients who use substances with care and compassion, rather than criminalizing, shaming, or infantilizing the individual’s responses to trauma and violence they have endured prior to, during, or after their substance use. Lastly, abolitionist praxis in the context of substance use treatment may require counselors to provide opportunities for clients to have input regarding their needs in treatment by prioritizing individualized treatment over a standardized “one size fits all” approach to counseling. Thus, rather than prescribing a course of treatment or implementing treatment prescribed by a referring carceral system, abolitionist praxis would leverage collaboration to allow clients to have a voice in determining what they need to cope and heal from their use of substances and any traumatic experiences that precede and result from substance use.

Cultural Competence and Advocacy
     Abolitionist praxis requires efforts to repair histories of structural violence (Cullors, 2019); thus, substance use counselors pursuing abolition must develop a critical understanding of the sociopolitical history of anti-drug policing toward those who use substances. This article provided a snapshot of this history as a starting point; however, counselors can delve further into learning about the intersection of anti-drug policing and race, gender, sexuality, disability, and socioeconomic status to develop more robust competence in addressing the scope of anti-drug policing. Counselors should critically reflect upon this historical knowledge to confront and actively dismantle any internalized biases they may have about substance use clients that are perpetuated by carceral systems. Counselors should specifically become aware of how the criminal legal system may perpetuate racial prejudice, particularly anti-Black racism, and how these attitudes affect the counselor’s conceptualization of their clients to avoid pathologizing or blaming the client for the structural violence they endure through anti-drug policing. To that end, counselors should actively incorporate practices that are not only trauma-informed, but also culturally responsive (SAMHSA, 2014).

Abolitionist praxis aimed at repairing historical structural violence through anti-drug policing would broadly include efforts toward the decriminalization of substance use. In addition to decriminalization efforts, counselors engaged in an abolitionist praxis might advocate with legal professionals and lawmakers for the retroactive and automatic expungement of drug-related criminal record charges for substance use clients (Adinoff & Reiman, 2019). These efforts would ensure that those with histories of substance use disorder are able to experience transformation that such records and their associated stigma may hinder. Given that abolition calls for counselors to address and promote healing from issues that underlie substance use, counselors seeking to engage in abolitionist praxis should advocate for funds that are currently and formerly used toward criminalizing substance use to be invested in transformative justice practices and trauma-informed treatment for substance use disorders (Adinoff & Reiman, 2019). For example, abolitionist praxis would call for transformative justice systems and practices to replace drug courts and related diversion programs. Although drug courts may be successful in deterring those who use substances from arrests and incarceration, Klukoff et al. (2021) highlighted the paradoxical nature of relying on carceral punishment as a motive for change because it risks police violence toward those who use substances when drug court requirements are not met. As stated earlier, this creates a value conflict for counselors who may have to disclose information regarding relapse during treatment that can be used in ways that jeopardize and harm the wellness of clients who use substances.

Limitations and Considerations

     Adopting and incorporating an abolitionist praxis to counseling with clients impacted by anti-drug policing comes with challenges that counselors must critically reflect on prior to and during the implementation of this practice. First, counselors should prepare themselves to navigate pushback and resistance to social justice practices that would disrupt the status quo (S. W. Davis & Fayter, 2021). For example, it is common for individuals to criticize abolitionist praxis as utopian to inhibit the process of creatively imagining communities and systems that do not rely on carceral logics and systems (Kaba, 2021). Approaches like motivational interviewing are poised to navigate these challenges from colleagues who may be hesitant to embark upon making abolitionist change. In addition to pushback from individuals, it should be noted that, as a praxis seeking the elimination of carceral systems, barriers to the adoption of an abolitionist praxis can be expected from current carceral systems and approaches that may have existing evidence that establish them as efficacious. To counteract this expected barrier, substance use counselors need to engage in research, assessment, and program evaluation of efforts that are developed in alignment with an abolitionist praxis to establish efficacy. This would serve the purpose of ensuring that progress toward safety is achieved, that substance use clients are receiving trauma-informed care, and that other substance use counselors are introduced to new alternatives to existing carceral approaches that may increase the risk of harm to substance use clients. Additionally, counselors should critically reflect on and identify solutions to ethical, legal, and employment-related barriers if implementing an abolitionist praxis on their own. For example, making the choice as an individual counselor in a broader agency to not report substance use to a referring probation officer may be construed as fraudulent and unethical, thus jeopardizing a counselor’s employment and career. When making these decisions about whether or not to report substance use, counselors need to carefully weigh the options and consider consequences that can come from each course of action from a legal and ethical perspective, similar to what is suggested in the Forester-Miller and Davis (2016) Ethical Decision-Making Model. In the meantime, counselors can inform and educate probation officers about the nature of addiction and the potential for relapse to occur. Increasing awareness about these matters could generate a landscape shift for how probation officers and other authorities treat those struggling with addiction. Lastly, counselors should consider advocating for organizational support to adopt and implement trauma-informed and abolitionist changes to prevent such outcomes.


Clients who meet criteria for substance use disorders may have experienced, have witnessed, or be vulnerable to experiencing police violence. As a result, those who use substances are vulnerable to experiencing trauma that stems from exposure to police violence, which counselors must address. Counselors need to utilize abolitionist praxis to achieve a trauma-informed practice that supports healing from experiences of trauma affiliated with substance use and police violence, aim to prevent retraumatization, and create opportunities for both accountability and repair of harm caused by one’s use of substances.

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


Adinoff, B., & Reiman, A. (2019). Implementing social justice in the transition from illicit to legal cannabis use. The American Journal of Drug and Alcohol Abuse, 45(6), 673–688.

Afuape, T., & Kerry Oldham, S. (2022). Beyond “solidarity” with Black Lives Matter: Drawing on liberation psychology and transformative justice to address institutional and community violence in young Black lives. Journal of Family Therapy, 44(1), 20–43.

Alang, S., McAlpine, D., McCreedy, E., & Hardeman, R. (2017). Police brutality and Black health: Setting the agenda for public health scholars. American Journal of Public Health, 107(5), 662–665.

Barrera, T. L., Mott, J. M., Hofstein, R. F., & Teng, E. J. (2013). A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clinical Psychology Review, 33(1), 24–32.

Beletsky, L., Grau, L. E., White, E., Bowman, S., & Heimer, R. (2010). The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs. Addiction, 106(2), 357–365.

Benson, B. L., Rasmussen, D. W., & Sollars, D. L. (1995). Police bureaucracies, their incentives, and the war on drugs. Public Choice, 83(1/2), 21–45.

Bor, J., Venkataramani, A. S., Williams, D. R., & Tsai, A. C. (2018). Police killings and their spillover effects on the mental health of Black Americans: A population-based, quasi-experimental study. The Lancet, 392(10144), 302–310.

Bride, B. E., Hatcher, S. S., & Humble, M. N. (2009). Trauma training, trauma practices, and secondary traumatic stress among substance abuse counselors. Traumatology, 15(2), 96–105.

Bryant-Davis, T., Adams, T., Alejandre, A., & Gray, A. A. (2017). The trauma lens of police violence against racial and ethnic minorities. Journal of Social Issues, 73(4), 852–871.

Bureau of Justice Statistics. (2021). Law enforcement.

Carrico, A. W., Flentje, A., Gruber V. A., Woods, W. J., Discepola, M. V., Dilworth, S. E., Neilands, T. B., Jain, J., & Siever, M. D. (2014). Community-based harm reduction substance abuse treatment with methamphetamine-using men who have sex with men. Journal of Urban Health, 91(3), 555–567.

Castelpietra, G., Knudsen, A. K. S., Agardh, E. E., Armocida, B., Beghi, M., Iburg, K. M., Logroscino, G., Ma, R., Starace, F., Steel, N., Addolorato, G., Andrei, C. L., Andrei, T., Ayuso-Mateos, J. L., Banach, M., Bärnighausen, T. W., Barone-Adesi, F., Bhagavathula, A. S., Carvalho, F., . . . Monasta, L. (2022). The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: Findings from the Global Burden of Disease Study 2019. The Lancet Regional Health: Europe, 16(100341), 1–18.

Chang, Z., Lichtenstein, P., Larsson, H., & Fazel, S. (2015). Substance use disorders, psychiatric disorders, and mortality after release from prison: A nationwide longitudinal cohort study. The Lancet Psychiatry, 2(5), 422–430.

Clark, C., Classen, C. C., Fourt, A., & Shetty, M. (2014). Treating the trauma survivor: An essential guide to trauma-informed care. Routledge.

Cook, J. M., Newman, E., & The New Haven Trauma Competency Group. (2014). A consensus statement on trauma mental health: The New Haven Competency Conference process and major findings. Psychological Trauma: Theory, Research, Practice, and Policy, 6(4), 300–307.

Cooper, H. L. F. (2015). War on drugs policing and police brutality. Substance Use & Misuse, 50(8–9), 1188–1194.

Cooper, H., Moore, L., Gruskin, S., & Krieger, N. (2005). The impact of a police drug crackdown on drug injectors’ ability to practice harm reduction: A qualitative study. Social Science & Medicine, 61(3), 673–684.

Cullors, P. (2019). Abolition and reparations: Histories of resistance, transformative justice, and accountability. Harvard Law Review, 132(6), 1684–1694.

Cullors, P. (2021). An abolitionist’s handbook: 12 steps to changing yourself and the world. St. Martin’s Press.

Davis, A. Y., Dent, G., Meiners, E. R., & Richie, B. E. (2022). Abolition. Feminism. Now. Haymarket Books.

Davis, C. S., Burris, S., Kraut-Becher, J., Lynch, K. G., & Metzger, D. (2005). Effects of an intensive street-level police intervention on syringe exchange program use in Philadelphia, PA. American Journal of Public Health, 95(2), 233–236.

Davis, S. W., & Fayter, R. (2021). Mutual aid as abolitionist praxis. Citizenship Studies, 25(2), 162–165.

DeVylder, J. E., Frey, J. J., Cogburn, C. D., Wilcox, H. C., Sharpe, T. L., Oh, H. Y., Nam, B., & Link, B. G. (2017). Elevated prevalence of suicide attempts among victims of police violence in the USA. Journal of Urban Health, 94, 629–636.

Dollar, C. B. (2019). Criminalization and drug “wars” or medicalization and health “epidemics”: How race, class, and neoliberal politics influence drug laws. Critical Criminology, 27(2), 305–327.

Drustrup, D., Kivlighan, D. M., & Ali, S. R. (2023). Decentering the use of police: An abolitionist approach to safety planning in psychotherapy. Psychotherapy, 60(1), 51–62.

El-Bassel, N., Gilbert, L., Witte, S., Wu, E., & Chang, M. (2011). Intimate partner violence and HIV among drug-involved women: Contexts linking these two epidemics—Challenges and implications for prevention and treatment. Substance Use & Misuse, 46(2–3), 295–306.

Farley, M., Golding, J. M., Young, G., Mulligan, M., & Minkoff, J. R. (2004). Trauma history and relapse probability among patients seeking substance abuse treatment. Journal of Substance Abuse Treatment, 27(2), 161–167.

Fazel, S., Yoon, I. A., & Hayes, A. J. (2017). Substance use disorders in prisoners: An updated systematic review and meta-regression analysis in recently incarcerated men and women. Addiction, 112(10), 1725–1739.

Federal Bureau of Investigation. (2022). Crime data explorer [Data set].

Forester-Miller, H., & Davis, T. E. (2016). Practitioner’s guide to ethical decision making (Rev. ed.).’s-guide-toethical-decision-making.pdf

Galovski, T. E., Peterson, Z. D., Beagley, M. C., Strasshofer, D. R., Held, P., & Fletcher, T. D. (2016). Exposure to violence during Ferguson protests: Mental health effects for law enforcement and community members. Journal of Traumatic Stress, 29(4), 283–292.

Geller, A., Fagan, J., Tyler, T., & Link, B. G. (2014). Aggressive policing and mental health of young urban men. American Journal of Public Health, 104(12), 2321–2327.

Giovengo, R. D. (2016). Training law enforcement officers. Routledge.

Global Burden of Disease Network. (2016). Global Burden of Disease Study 2015 (GBD 2015) life expectancy, all-cause and cause-specific mortality 1980-2015 [Data set]. Institute for Health Metrics and Evaluation.

Good, D., Leichtling, G., & Pustejovsky, S. (2023). Oregon decriminalizes drugs: A state-level process evaluation of early implementation. Coimagine Health and Vital Strategies.

Green, D. A. (2022, May 10). Developing competence to address undue police violence. Counseling Today.

Green, D. A., & Evans, A. M. (2021). Undue police violence toward African Americans: An analysis of professional counselors’ training and perceptions. Journal of Counseling & Development, 99(4), 363–371.

Green, D. A., Evans, A. M., Litam, S. D. A., Hornsby, T., Boulden, R., Shannon, J., Ford, D. J., & Landrum, D. (2024). Racial identity attitudes and vicarious traumatization from undue police violence on anticipatory traumatic reaction among Black Americans. Journal of Interpersonal Violence, 39(3–4), 848–868.

Hayashi, K., Ti, L., Csete, J., Kaplan, K., Suwannawong, P., Wood, E., & Kerr, T. (2013). Reports of police beating and associated harms among people who inject drugs in Bangkok, Thailand: A serial cross-sectional study. BMC Public Health, 13(1), 733.

Heffner, J. L., Blom, T. J., & Anthenelli, R. M. (2011). Gender differences in trauma history and symptoms as predictors of relapse to alcohol and drug use. The American Journal on Addictions, 20(4), 307–311.

Jacobs, L. A., Kim, M. E., Whitfield, D. L., Gartner, R. E., Panichelli, M., Kattari, S. K., Downey, M. M., McQueen, S. S., & Mountz, S. E. (2021). Defund the police: Moving towards an anti-carceral social work. Journal of Progressive Human Services, 32(1), 37–62.

James, S. L., Castle, C. D., Dingels, Z. V., Fox, J. T., Hamilton, E. B., Liu, Z., Roberts, N. L. S., Sylte, D. O., Henry, N. J., LeGrand, K. E., Abdelalim, A., Abdoli, A., Abdollahpour, I., Abdulkader, R. S., Abedi, A., Abosetugn, A. E., Abushouk, A. I., Adebayo, O. M., Agudelo-Botero, M., Ahmad, T., . . . Vos, T. (2020). Global injury morbidity and mortality from 1990 to 2017: Results from the Global Burden of Disease Study 2017. Injury Prevention, 26(Supp 1), i96–i114.

Joe, J. R., Shillingford-Butler, M. A., & Oh, S. (2019). The experiences of African American mothers raising sons in the context of #BlackLivesMatter. The Professional Counselor, 9(1), 67–79.

Kaba, M. (2021). We do this ’til we free us: Abolitionist organizing and transforming justice. Haymarket Books.

Kaba, M., & Ritchie, A. J. (2022). No more police: A case for abolition. New Press.

Kinner, S. A., Forsyth, S., & Williams, G. (2012). Systematic review of record linkage studies of mortality in ex-prisoners: Why (good) methods matter. Addiction, 108(1), 38–49.

Klukoff, H., Kanani, H., Gaglione, C., & Alexander, A. (2021). Toward an abolitionist practice of psychology: Reimagining psychology’s relationship with the criminal justice system. Journal of Humanistic Psychology, 61(4), 451–469.

Koram, K. (2022). Drug prohibition and the policing of warfare: The war on drugs, globalization, and the moralization of perpetual violence. Humanity, 13(1), 22–39.

Krieger, N., Chen, J. T., Waterman, P. D., Kiang, M. V., & Feldman, J. (2015). Police killings and police deaths are public health data and can be counted. PLOS Medicine, 12(12), e1001915.  

Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on violence and health. The Lancet, 360(9339), 1083–1088.

Lunze, K., Lunze, F. I., Raj, A., & Samet, J. H. (2015). Stigma and human rights abuses against people who inject drugs in Russia—A qualitative investigation to inform policy and public health strategies. PLOS One, 10(8), e0136030.

Maher, L. (2004). Drugs, public health and policing in Indigenous communities. Drug and Alcohol Review, 23(3), 249–251.

Meade, B., Steiner, B, & Klahm, C. F., IV. (2017). The effect of police use of force on mental health problems of prisoners. Policing and Society, 27(2), 229–244.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford.

Moh, Y. S., & Sperandio, K. R. (2022). The need to consider requiring trauma training in entry-level academic training programs in clinical mental health counseling. Journal of Mental Health Counseling, 44(1), 18–31.

Motley, R. O., Jr., Byansi, W., Siddiqi, R., Bills, K. L., & Salas-Wright, C. P. (2022). Perceived racism-based police use of force and cannabis use among Black emerging adults. Addictive Behaviors Reports, 15, 100430.

Mott, J. M., Sutherland, R. J., Williams, W., Lanier, S. H., Ready, D. J., & Teng, E. J. (2013). Patient perspectives on the effectiveness and tolerability of group-based exposure therapy for posttraumatic stress disorder: Preliminary self-report findings from 20 veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 5(5), 453–461.

New York Civil Liberties Union. (n.d.). Ligon v. City of New York (challenging the NYPD’s aggressive patrolling of private apartment buildings).

New York Civil Liberties Union. (2019, March 14). Stop-and-frisk in the de Blasio era (2019).

Park, J. N., Linton, S. L., Sherman, S. G., & German, D. (2019). Police violence among people who inject drugs in Baltimore, Maryland. International Journal of Drug Policy, 64, 54–61.

Pinals, D. A., Gaba, A., Clary, K. M., Barber, J., Reiss, J., & Smelson, D. (2019). Implementation of MISSION–Criminal Justice in a treatment court: Preliminary outcomes among individuals with co-occurring disorders. Psychiatric Services, 70(11), 1044–1048.

Pombo, S., & da Costa, N. F. (2016). Heroin addiction patterns of treatment-seeking patients, 1992-2013: Comparison between pre-and post-drug policy reform in Portugal. Heroin Addiction & Related Clinical Problems, 18(6), 51–60.

Pratt, D., Appleby, L., Piper, M., Webb, R., & Shaw, J. (2010). Suicide in recently released prisoners: A case-control study. Psychological Medicine, 40(5), 827–835.

Purnell, D. (2021a). Reforms are the master’s tools: The system is built for power, not justice. In C. Kaepernick (Ed.) Abolition for the people: The movement for a future without policing and prisons. Kaepernick Publishing.

Purnell, D. (2021b). Becoming abolitionists: Police, protests, and the pursuit of freedom. Astra House.

Rhodes, T., Platt, L., Sarang, A., Vlasov, A., Mikhailova, L., & Monaghan, G. (2006). Street policing, injecting drug use and harm reduction in a Russian city: A qualitative study of police perspectives. Journal of Urban Health, 83(5), 911–925.

Saleem, O. (1997). The age of unreason: The impact of reasonableness, increased police force, and colorblindness on Terry “Stop and Frisk.” Oklahoma Law Review, 50(4), 451–493.

Sarang, A., Rhodes, T., Sheon, N., & Page, K. (2010). Policing drug users in Russia: Risk, fear, and structural violence. Substance Use & Misuse, 45(6), 813–864.

Schwartze, D., Barkowski, S., Strauss, B., Knaevelsrud, C., & Rosendahl, J. (2019). Efficacy of group psychotherapy for posttraumatic stress disorder: Systematic review and meta-analysis of randomized controlled trials. Psychotherapy Research, 29(4), 415–431.

Scott, C. L. (2020). Jail diversion: A practical primer. CNS Spectrums, 25(5), 651–658.

Shannon, K., Rusch, M., Shoveller, J., Alexson, D., Gibson, K., & Tyndall, M. W. (2008). Mapping violence and policing as an environmental–structural barrier to health service and syringe availability among substance-using women in street-level sex work. International Journal of Drug Policy, 19(2), 140–147.

Shaw, S. A., El-Bassel, N., Gilbert, L., Terlikbayeva, A., Hunt, T., Primbetova, S., Rozental, Y., & Chang, M. (2016). Depression among people who inject drugs and their intimate partners in Kazakhstan. Community Mental Health Journal, 52, 1047–1056.

Sloan, D. M., Feinstein, B. A., Gallagher, M. W., Beck, J. G., & Keane, T. M. (2013). Efficacy of group treatment for posttraumatic stress disorder symptoms: A meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 5(2), 176–183.

Small, W., Rhodes, T., Wood, E., & Kerr, T. (2007). Public injection settings in Vancouver: Physical environment, social context and risk. International Journal of Drug Policy, 18(1), 27–36.

Smiley-McDonald, H. M., Attaway, P. R., Wenger, L. D., Greenwell, K., Lambdin, B. H., & Kral, A. H. (2023). “All carrots and no stick”: Perceived impacts, changes in practices, and attitudes among law enforcement following drug decriminalization in Oregon State, USA. International Journal of Drug Policy, 118, 1–10.

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach.

Sweeney, A., & Taggart, D. (2018). (Mis)understanding trauma-informed approaches in mental health. Journal of Mental Health, 27(5), 383–387.

Tapp, S. N., & Davis, E. (2022). Contacts between police and the public, 2020. (BJS Publication No. NCJ 304527). Bureau of Justice Statistics.

Ti, L., Hayashi, K., Kaplan, K., Suwannawong, P., Wood, E., Montaner, J., & Kerr, T. (2013). HIV test avoidance among people who inject drugs in Thailand. AIDS and Behavior, 17, 2474–2478.

Tonry, M. (1994). Racial politics, racial disparities, and the war on crime. Crime & Delinquency, 40(4), 475–494.

Vallance, K., Stockwell, T., Pauly, B., Chow, C., Gray, E., Krysowaty, B., Perkin, K., & Zhao, J. (2016). Do managed alcohol programs change patterns of alcohol consumption and reduce related harm? A pilot study. Harm Reduction Journal, 13(1), 13.

Volkmann, T., Lozada, R., Anderson, C. M., Patterson, T. L., Vera, A., & Strathdee, S. A. (2011). Factors associated with drug-related harms related to policing in Tijuana, Mexico. Harm Reduction Journal, 8, 7.

Werb, D., Rowell, G., Guyatt, G., Kerr, T., Montaner, J., & Wood, E. (2011). Effect of drug law enforcement on drug market violence: A systematic review. International Journal of Drug Policy, 22(2), 87–94.

Werb, D., Strathdee, S. A., Vera, A., Arredondo, J., Beletsky, L., Gonzalez-Zuniga, P., & Gaines, T. (2016). Spatial patterns of arrests, police assault and addiction treatment center locations in Tijuana, Mexico. Addiction, 111(7), 1246–1256.

The White House. (2022, August 1). Fact sheet: President Biden’s Safer America Plan.

Wood, E. F., Werb, D., Beletsky, L., Rangel, G., Mota, J. C., Garfein, R. S., Strathdee, S. A., & Wagner, K. D. (2017). Differential experiences of Mexican policing by people who inject drugs residing in Tijuana and San Diego. International Journal of Drug Policy, 41, 132–139.

Darius A. Green, PhD, NCC, is an assistant professor at the University of Colorado Colorado Springs. Katharine R. Sperandio, PhD, NCC, ACS, LPC, is an assistant professor and a CACREP-accreditation coordinator at Saint Joseph’s University. Correspondence may be addressed to Darius A. Green, 1420 Austin Bluffs Pkwy, Colorado Springs, CO 80918,

A Qualitative Analysis of Ableist Microaggressions

Jennifer M. Cook, Melissa D. Deroche, Lee Za Ong

The phenomenon of microaggressions is well established within the counseling literature, particularly as it relates to race, ethnicity, gender, and affectual orientation. However, research related to disability or ableist microaggressions is still in its infancy, so counseling professionals have limited information about experiences of disability and ableist microaggressions. The purpose of this qualitative content analysis was to describe participants’ self-reported experiences with ableist microaggressions. Participants (N = 90) had a diagnosed disability and the majority (91.11%) identified as having two or more nondominant identities beyond their disability. We report two categories and 10 themes. While participants were part of the general population, we position our discussion and implications within the context of professional counseling to increase counseling professionals’ awareness and knowledge so counselors can avoid ableist microaggressions and provide affirmative counseling services to persons with disabilities.

Keywords: disability, ableist microaggressions, professional counseling, nondominant identities, affirmative counseling

Day by day, what you choose, what you think, and what you do is who you become.
—Heraclitus, pre-Socratic philosopher

     Each person is a complex makeup of dominant and nondominant sociocultural identities. Individuals with dominant cultural identities (e.g., able-bodied, White, middle social class) experience societal privilege, have more sociocultural influence, and have unencumbered access to resources. People with nondominant identities, including people with disabilities (PWD), people of color, and people in lower social class, frequently have less influence and experience structural and interpersonal inequities, limitations, and discrimination (Sue & Spanierman, 2020). As such, people with nondominant identities often experience microaggressions. Microaggressions are unintentional or deliberate verbal, nonverbal, and/or environmental messages that convey disapproval, distaste, and condemnation of an individual based on their nondominant identity (Sue et al., 2007).

Professional counselors are aware and knowledgeable that their identity constellation and their
experiences with microaggressions, as well as those of their clients, impact their worldviews, experiences, and—importantly—the counseling relationship (Ratts et al., 2016). While microaggressions associated with several cultural identities have been well-researched within counseling (e.g., race, ethnicity, gender, affectual orientation), others, like ableist microaggressions, have been examined far less frequently (Deroche et al., 2024). The purpose of this article is to describe the microaggression experiences that PWD (N = 90) encounter. Our intention is to increase counseling professionals’ awareness and knowledge about ableist microaggressions so they can examine their beliefs about disability, identify how they may have participated in ableist microaggressions and, ultimately, provide affirmative counseling services to PWD.

Literature Review

Although the term microaggressions was coined by Pierce in the 1970s, it was not until 2007 that it took hold within the allied helping professions (Sue et al., 2007). Initially, the term was used to describe experiences based on race, yet the term has been applied more broadly to the dismissive experiences people with other nondominant identities (e.g., gender, affectual/sexual orientation) encounter (Sue & Spanierman, 2020). In 2010, Keller and Galgay initiated foundational research about the microaggressions that PWD experience. Through their qualitative study, they identified eight microaggression domains experienced by PWD and described their harmful effects on the psychological and emotional well-being of PWD. Those eight domains are: (a) denial of identity, (b) denial of privacy, (c) helplessness, (d) secondary gain, (e) spread effect, (f) patronization, (g) second-class citizenship, and (h) desexualization (i.e., ignoring or avoiding the sexual needs, wants, or desires of PWD). This study marked the beginning of ableist microaggressions research that led scholars not only to naming (e.g., Dávila, 2015) and measuring (e.g., Conover et al., 2017a) specific microaggressions toward PWD, but also describing experiences with ableist microaggressions within specific disability groups (e.g., Coalson et al., 2022; Eisenman et al., 2020) and exploring the impact for specific cultural groups of PWD (e.g., Miller & Smith, 2021).

Before continuing further, it is important for us to explain our use of the term ableist microaggressions, rather than the term disability microaggressions, because it deviates from the typical convention used to name microaggressions (e.g., racial microaggressions, gender microaggressions). While some authors have used the term disability microaggressions (e.g., Dávila, 2015), we believe that this term undercuts and minimizes PWD’s microaggression experiences, as it fails to explicitly communicate that these microaggressions are forms of ableism. Therefore, to validate PWD’s experiences and to align with the disability movement’s philosophy of diversity and social justice, we use the term ableist microaggressions (Perrin, 2019).

The qualitative ableist microaggression studies we reviewed all utilized and endorsed the themes Keller and Galgay (2010) found in their qualitative study, while adding nuance and new information about ableist microaggressions. For instance, Olkin et al.’s (2019) focus group research with women who had both hidden and apparent disabilities (N = 30) supported Keller and Galgay’s eight themes while identifying two others: medical professionals not believing PWD’s symptoms and experiences of having their disability discounted based on appearing young and/or healthy. Similarly, Coalson et al. (2022), who utilized focus groups with adults who stutter (N = 7), endorsed six of Keller and Galgay’s themes and identified participants’ perceptions of microaggressive behaviors (i.e., Exonerated the Listener, Benefit of the Doubt, Focusing on Benefits, and Aggression Viewed as Microaggression) while noting that some participants had minimal or no microaggression experiences.

Although Eisenman et al. (2020) endorsed five of Keller and Galgay’s (2010) themes, they took a different approach to how they analyzed and organized their findings by using Sue et al.’s (2007) microaggression taxonomy. Of note, these researchers were the first to identify and establish microaffirmations within disability microaggressions research. According to Rolón-Dow and Davison (2018) microaffirmations are:

behaviors, verbal remarks or environmental cues experienced by individuals from minoritized racial groups in the course of their everyday lives that affirm their racial identities, acknowledge their racialized realities, resist racism or advance cultural and ideological norms of racial justice. (p. 1)

Like microaggressions, microaffirmations may be intentional or unintentional, but they have a positive rather than a negative impact on people with nondominant racial identities. Eisenman et al. (2020) found all four race-related microaffirmation types identified by Rolón-Dow and Davison (2021)—Microrecognitions, Microvalidations, Microtransformations, and Microprotections—with their sample of people with intellectual disabilities.

Finally, Miller and Smith (2021) conducted individual interviews (N = 25) with undergraduate and graduate students who identified as members of the LGBTQ community with a disability. They, too, found Keller and Galgay’s (2010) domains present in their study and identified eight additional categories. Five categories captured cultural components in addition to disability (i.e., Biphobia, Intersectionality Microaggression, Queer Passing/Disclosure, Racism, and Sexism), while the remaining three were specific to ableist microaggression–focused data: Ableism Avoidance, Faculty Accommodations, and Structural Ableism/Inaccessibility.

The purpose of our study is to add to the burgeoning disability and microaggressions discourse by analyzing participants’ responses to a qualitative prompt offered to them after they completed the Ableist Microaggression Scale (AMS; Conover et al., 2017b). We corroborate prior research findings while adding novel findings that increase professional knowledge about ableist microaggressions and their impact.


To ensure compliance with Section 508 of the Rehabilitation Act, the federal law that requires PWD to have access to electronic information equivalent to that available to nondisabled individuals, we utilized digital accessibility tools on the internet platform used for this study (Qualtrics) and recruited PWD to test the accessibility of the study survey and questions. The data analyzed and reported in this article were part of a larger, IRB-approved study (N = 201) in which we investigated participants’ ableist microaggression experiences quantitatively using the AMS (Conover et al., 2017b) to uncover whether participants’ AMS scores were impacted by visibility of disability, type of disability, and their other nondominant identities (Deroche et al., 2024). After participants completed the survey, they were invited to provide a written response to the open-ended question: “What, if any, information do you think would be helpful for us to know about your personal experiences regarding ableist microaggressions?” Ninety participants (44.77% of the overall sample) responded with rich data that warranted analysis and reporting in an independent article. Because the open-ended question occurred after participants completed the AMS, we agreed that the survey likely influenced their responses, so we chose to conduct a content analysis using an a priori codebook grounded in the AMS subscales (Minimization, Denial of Personhood, Otherization, and Helplessness; Conover et al., 2017b), with additional coding categories for data that did not fit the a priori codes (i.e., Fortitude/Resilience/Coping, Contextual Factors, Impact of Microaggressions/Ableism on Mental Health/Wellness, Microaggression Experiences Are Different Depending on Visibility of Disability, Internalized Ableism, and Microaggressions Include Identities Other Than Disability).

     Using online data collection via Qualtrics survey, we recruited participants nationally by contacting disability organizations, listservs, social media, and professional contacts who work with organizations that serve PWD. The recruitment included a description of the research; inclusion criteria; and a confidential, anonymized survey link. The survey was Section 508–compliant and optimized to be taken on a computer or mobile device. Data were collected over a 3-month period.

Inclusion Criteria and Participants
     To participate in the study, individuals (a) were at least 18 years of age, (b) had earned a high school diploma or GED, and (c) had a diagnosed disability. Under the Americans with Disabilities Act (ADA), the term disability is defined within the context of a person’s significant limitations to engage in major life activities. Different agencies and organizations such as the World Health Organization and the U.S. Social Security Administration define disability differently (Patel & Brown, 2017). For this study, we categorized disability as (a) physical disability (i.e., mobility-related disability), (b) sensory disability (i.e., seeing- or hearing-related disability), (c) psychiatric/mental disability (e.g., bipolar disorder, depression, post-traumatic stress disorder), or (d) neurodevelopmental disability (e.g., autism spectrum disorder, learning disability, or ADHD). Participants’ disabilities were apparent/visible (i.e., recognizable by others without the person disclosing they have a disability) or hidden (i.e., others are unlikely to know the individual has a disability, so the person must disclose they have a disability for it to be known), and they could identify with one or more disability categories listed above. Ninety individuals provided usable responses. Table 1 details participant demographics. The bulk of the sample, 84.43%, identified as having two (36.66%), three (26.66%), or four (21.11%) nondominant cultural identities out of the six identities the study targeted, while the rest of the sample comprised individuals who noted six (n = 2; 2.22%), five (n = 4; 4.4%), one (n = 7; 7.77%), or no (n = 1; 1.11%) nondominant identities.

Of note, a higher percentage of participants with hidden or both apparent and hidden disabilities participated in the qualitative portion of the study compared to those who completed only the quantitative portion (45.5% compared to 41.8% and 33.3% compared to 27.4%, respectively). Similarly, there was a lower response rate from participants who earned a high school diploma or GED (5.6%), completed an associate degree or trade school (7.8%), completed some college (7.8%), or earned a doctoral degree (10%). There was an increase in responses from participants who earned a bachelor’s degree (26.7% compared to 21.9% in the quantitative portion) or a master’s degree (42.2% compared to 35.8%, respectively).

Data Analysis
     We analyzed data for this study using MacQueen et al.’s (1998) framework to create a codebook to promote coder consistency. We established six codes, four of which were definitionally congruent with the AMS subscales (i.e., Helplessness, Minimization, Denial of Personhood, and Otherization; Conover et al., 2017a). While we used Conover et al.’s definitions as the foundation, we utilized Keller and Galgay’s (2010) definitions to add additional nuance. The next code, Other Data, was an a priori code reserved for data that did not fit the AMS subscale codes. After completing the pilot, we added a sixth code, Fortitude/Resilience/Coping, to capture data that demonstrated ways in which participants developed strengths, dealt with adversity and microaggressions, and persevered despite their microaggressive experiences. Identifying PWD’s fortitude/resilience/coping abilities is indicative of a strengths-based framework that promotes inclusion, equity, and higher quality of life. Research has shown that resilience in PWD such as improved well-being, higher social role satisfaction, and lower mental health symptoms are correlated with positive psychological and employment outcomes (Ordway et al., 2020; Norwood et al., 2022).  Once this code was established, the Other Data code was used for any data that did not fit the five a priori codes. After the pilot, we added to the codebook definitions for clarity—though no codes were changed. All codes we established had substantial representation in the data and are reported as themes in the results section. The auditor (second author Melissa D. Deroche) gave feedback on the codebook and confirmed the codebook was sound prior to analysis.

Table 1
Demographic Characteristics of Participants (N = 90)

Variable        n          %
Disability Type
Single Type: Physical 21 23.33
Single Type: Sensory 17 18.88
Single Type: Neurodevelopmental 6 6.66
Single Type: Psychiatric/Mental Health 6 6.66
Combination (2): Physical and Psychiatric/Mental Health 8 8.88
Combination (2): Neurodevelopmental and Psychiatric/Mental Health 6 6.66
Combination (2): Sensory and Psychiatric/Mental Health 5 5.55
Combination (2): Sensory and Physical 4 4.44
Combination (2): Neurodevelopmental and Physical 2 2.22
Combination (2): Sensory and Neurodevelopmental 2 2.22
Combination (3): Physical, Psychiatric/Mental Health, Neurodevelopmental 4 4.44
Combination (3): Physical, Sensory, Neurodevelopmental 4 4.44
Combination (3): Sensory, Psychiatric/Mental Health, Neurodevelopmental 2 2.22
Combination (3): Physical, Sensory, Psychiatric/Mental Health 1 1.11
Combination (4): Physical, Sensory, Psychiatric/Mental Health,


2 2.22
Visibility of Disability
Visible/Apparent 19 21.11
Hidden/Concealed 41 45.55
Both 30 33.33
Biological Sex/Sex Assigned at Birth
Female 74 82.22
Male 16 17.77
Gender Identity
Gender Fluid/Gender Queer 6 6.66
Man 16 17.77
Woman 68 75.55
Affectual/Sexual Orientation
Asexual 2 2.22
Bisexual 9 10.00
Gay 2 2.22
Heterosexual 68 75.55
Lesbian 3 3.33
Pansexual 4 4.44
Queer 1 1.11
Questioning 1 1.11
Racial/Ethnic Identity
African American/Black 4 4.44
Asian or Pacific Islander 3 3.33
Biracial 2 2.22
Euro-American/White 69 76.66
Indigenous 1 1.11
Jewish 5 5.55
Latino/a or Hispanic 3 3.33
Middle Eastern 1 1.11
Multiracial 2 2.22
Religious/Spiritual Identity
Atheist 8 8.88
Catholic 12 13.3
Jewish 4 4.44
Not Religious 1 1.11
Pagan 1 1.11
Protestant 36 40.00
Questioning 2 2.22
Spiritual Not Religious 5 5.55
Unitarian Universalist 2 2.22
Self-Identify in Another Way 19 21.11
Highest Level of Education
High School Diploma or GED 5 5.55
Associate or Trade School Degree 7 7.77
Some College, No Degree 7 7.77
Bachelor’s Degree 24 26.66
Master’s Degree 38 42.22
PhD, EdD, JD, MD, etc. 9 10.00
No Response 1 1.11
Employment Status
Full-Time 40 44.44
Part-Time 16 17.77
Retired 9 10.00
Student 11 12.22
Unemployed 14 15.55
Employment Compared to Training and Skills
Training/Education/Skills are lower than job responsibilities/position 2 2.22
Training/Education/Skills are on par with job responsibilities/position 42 46.66
Training/Education/Skills exceed job responsibilities/position 24 26.66
Not applicable 22 24.44

We began analysis by piloting 10% of the data (n = 9) using the initial codebook (Boyatzis, 1998). Two researchers (first and third authors Jennifer M. Cook and Lee Za Ong) coded data independently and then worked together to reach consensus. Once the pilot analysis was complete, we coded the remaining data and recoded pilot data to ensure they fit the revised coding frame. After all data were coded, we further coded the data that were assigned to Other Data using in vivo codes to establish codes that best captured the data. We identified five codes within Other Data: Contextual Factors, Impact of Microaggressions/Ableism on Mental Health/Wellness, Microaggression Experiences Are Different Depending on Visibility of Disability, Internalized Ableism, and Microaggressions Include Identities Other Than Disability. 

     Cook and Ong coded all data independently and then met to reach consensus. Prior to coding commencement, we identified our beliefs and potential biases about the data and discussed how they might impact coding; we continued these conversations throughout analysis. For the pilot coding phase, independent coder agreement prior to consensus was 40%. Independent coder agreement prior to consensus during regular coding was 56%, and 69% for Other Data independent coding. We reached consensus for all coded data through a team meetings consensus process (Boyatzis, 1998). Finally, we utilized an auditor (Deroche). Deroche reviewed all consensus findings during all analysis stages. The coding team met with the auditor to resolve questions and discrepancies, such as a few instances in which data were misassigned to a code.

Research Team
     The research team comprised three cisgender women between the ages of 45 and 55 who are all licensed professional counselors and work as counselor educators. Cook and Deroche identify as White and hold PhDs in counselor education, while Ong holds a PhD in rehabilitation psychology and is Asian American of Chinese descent and an immigrant from Malaysia. Deroche identifies as a person with a disability, Deroche and Ong have worked extensively with PWD, and all three authors have conducted research about PWD. Cook has abundant publications in qualitative research designs related to multicultural counseling. Finally, all three authors have extensive research training and experience in qualitative and quantitative research designs.


The findings described below are organized into two categories: findings that align with the AMS subscales and unique findings that are independent of the AMS subscales. Themes are listed in their appropriate category with participants’ quotes to illustrate and substantiate each theme (see Table 2). When we provide participant quotes, we refer to them by their randomly assigned participant numbers (e.g., P105, P109).

Table 2
Categories and Themes

Category/Theme      n % of Sample
Category 1: Findings That Align With the AMS Subscales
Minimization 35           38.88
Denial of Personhood 26           28.88
Otherization 17           18.88
Helplessness 16           17.77
Category 2: Unique Findings Independent of the AMS Subscales
Fortitude/Resilience/Coping 27           30.00
Contextual Factors 17           18.88
Impact of Microaggressions/Ableism on Mental Health/Wellness 10             9.00
Microaggression Experiences Are Different Depending on Visibility of Disability 6             6.66
Internalized Ableism 4             4.44
Microaggressions Include Identities Other Than Disability 4             4.44

Note. N = 90.

Category 1: Findings That Align With the AMS Subscales
     Our analysis revealed that the AMS a priori codes fit the study data. As such, the codes were transitioned to themes: Minimization (n = 35), Denial of Personhood (n = 26), Otherization (n = 17), and Helplessness (n = 16). The quotes selected for each theme illustrate the lived experiences of the theme definitions and add context and nuance about the impact of ableist microaggressions.

     Conover et al. (2017a) defined Minimization as microaggression experiences demonstrating the belief that PWD are “overstating their impairment or needs” and that “individuals with a disability could be able-bodied if they wanted to be or that they are actually able-bodied” (p. 581). Thirty-five of the 90 participants’ responses (33.33%) indicated instances of Minimization.

For example, P105 described incidents from their formative years that highlight the belief that PWD are, in fact, able-bodied and overstating their impairment:

As a child, children and adults alike would test the limits of my blindness. My piers [sic] would ask me how many fingers they were holding up. And in one instance, teachers lined a hallway with chairs to see if I’d run into them. Spoiler alert, I did.

P109 spoke to their interactions with family that highlight how disbelief about a person’s disability can result in Minimization:

Family is really bad. They still don’t believe me. I was asked (when I couldn’t climb stairs into a restaurant) are you trying to make a point? My visible disability has gotten worse over 40 years. I think because they saw me before I started using a cane, they just won’t believe me.

P158 illuminated a fallacy that can result in Minimization: “Because my disability is invisible people assume I need no help, [and] when I do, they discount my disability. I hear, ‘you don’t look like you have a disability‚’ ‘don’t sell yourself short.’”

Finally, P137 spoke to the blame that underlies Minimization:

On[e] of the most frequent microaggressions encountered living with my particular invisible disability (type 1 diabetes) is the ableist idea that health is entirely a personal responsibility. There is this assumption that whatever problems we face with our health are a direct result of poor choices (dietary, financial) completely ignoring the systematic problems with for-profit health care in this country.

Denial of Personhood
     Denial of Personhood is characterized by PWD being “treated with the assumption that a physical disability indicates decreased mental capacity and therefore, being reduced to one’s physicality” (Conover et al., 2017a, p. 581); such microaggressions can occur “when any aspect of a person’s identity other than disability is ignored or denied” (Keller & Galgay, 2010, p. 249). Twenty-six participants (28.88%) endorsed this theme. For example, P142 described their experiences in the workplace that illustrate the erroneous belief that PWD have diminished mental capacity: “All my life I was pushed out of jobs for not hearing. People would actually tell me, ‘if you can’t hear—how can you do anything’ even though all my performance reviews exceeded expectations.” P123 spoke to a similar sentiment: “[I] am often asked ‘what’s wrong with you?’ ‘how did you get through college?’” Finally, P173 summarized the belief that seemingly underlies Denial of Personhood microaggressions and issued a corrective action:

Disabled doesn’t mean stupid. We can figure out most things for ourselves and if we can’t we know to ask for help. Don’t tell us how to live our lives or say we don’t deserve love, happiness and children. If you don’t know the level of someone’s disability you shouldn’t have the right to judge them about such things.

     Seventeen participants (18.88%) described Otherization as part of their narrative responses. Otherization microaggressions are those in which PWD are “treated as abnormal, an oddity, or nonhuman, and imply people with disabilities are or should be outside the natural order” (Conover et al., 2017a, p. 581) and that their “rights to equality are denied” (Keller & Galgay, 2010, p. 249). Participants shared several examples of these types of microaggressions. For instance, P140 shared:

When we (PWD) ask for simple things (e.g., can you turn on the captioning) and people grumble, say they can’t, etc. it just reinforces that we’re not on equal footing and at least for me it eats away a little bit every time.

P185 indicated another manifestation of Otherization: “As a deaf person, I get frustrated when whoever I’m talking to stops listening when someone else (non-deaf person) speaks verbally, leaving me mid-sentence.” P108 shared that they have been “prayed for in public without asking,” while P106 expressed, “I hate when people compliment me on how well I push my chair or say I must have super strong arms. I just have normal arms not athletic looking or anything.” 

     Helplessness microaggressions are those in which PWD are “treated as if they are incapable, useless, dependent, or broken, and imply they are unable to perform any activity without assistance” (Conover et al., 2017a, p. 581). Sixteen participants (17.77%) described Helplessness microaggressions. For P174, the most common Helplessness microaggression they experience is when “people speak to the person I am with instead of to me. Drives me crazy! Worse is when the person I’m with answers for me.” P126 corroborated the “devastating” nature of when “people make decisions for you.” P129 shared that, “As a person with an invisible disability, I most often encounter microaggressions in the form of unsolicited advice when I disclose my disability.” Similarly, P134 noted:

Although my disability is not apparent, if people know about it, they often just act on my behalf without asking me for input or feedback. That is very frustrating and often does not change even if I bring it up to the individual who does it.

This final quote from P134 is powerful because it, like P174’s experience, demonstrates how people without disabilities participate in perpetuating ableism even when they were not the ones who initiated it.

Category 2: Unique Findings Independent of the AMS Subscales
     As we indicated earlier, we separated data that did not fit into AMS codes and coded them using in vivo codes. This analysis resulted in six novel themes (i.e., Fortitude/Resilience/Coping, Contextual Factors, Impact of Microaggressions/Ableism on Mental Health/Wellness, Microaggression Experiences Are Different Depending on Visibility of Disability, Internalized Ableism, and Microaggressions Include Identities Other Than Disability) that are independent from the AMS-driven themes discussed in the prior section, yet are interrelated because they add unique insights and helpful context for understanding ableist microaggressions within the lived experiences of PWD.

     We defined Fortitude/Resilience/Coping as ways in which participants have developed strength, dealt with adversity/microaggressions, and persevered despite their microaggressive experiences. Thirty percent (n = 27) of participants disclosed a wide range of attitudinal and experiential tactics related to this theme. P103 shared, “I maintain what I call a healthy sense of humor about my own body and being disabled,” while P145 demonstrated a sense of humor as they shared how they cope:

I just have to remind them and myself that my brain works differently and that I am just as competent as anyone else. I have learned not to beat myself up when I forget something or can’t get my paperwork done correctly for the tenth time. (I really hate paperwork.)

Participants 138 and 127 both spoke directly to the role knowledge plays. P138 shared:

I want to put out there that knowledge & understanding are power. Knowing & understanding your rights as a person with a disability as well as knowing & understanding your unique experience with your own disability (to the best of your ability) is key to making forward strides in environments that can often times feel ableist.

P127 spoke to knowledge, too, with their belief that “most microaggressions stem from a lack of education. I am often the first person they have met with a disability and the experience makes them uncomfortable.”

Finally, P187 spoke to the power of their resilience and its impact on their life, experiences which they draw from to help others:

I’ve been physically and emotionally abused my entire life, until I took control and stopped it. I’m middle aged and it took me 40 years to forgive everything that I’ve . . . had to endure. Never from my family, or close friends, but it’s been a difficult life, and now I’m all ok with it and try to help others with disabilities that are having a hard time.

Contextual Factors
     Seventeen participants (18.88%) described Contextual Factors, which are data that depict relational, situational, or environmental elements that impact participants’ experiences of ableist microaggressions.

P110 shared thatmicroaggressions can be hard to label because they can vary based on the relationship you have with the person.” P175 added: “Most times the microaggression I receive are by people when they don’t know me, or first meet me, as opposed to get to know me better.” P162 spoke to additional situational/relational nuances: “I have very different experiences depending on what assistive technology I’m using in a given space (basically to what degree I pass as able-bodied) and how people know me.”

P163 spoke to relational roles as well as environmental context: “The attitudes about me are distinctly divided between the power structures. A case manager, medical doctor, neighbor or family member will certainly show their attitude differently. The same goes for academic settings [versus] job placement.” For P152, “The worst comments have come from mental health therapists [who] are medical professionals who should be the most compassionate towards their patients.”

P117 and P131 both identified situational differences they have noticed. P117 shared, “I find that people have treated me differently at different ages and stages in my life, particularly when I was raising three children as a divorced mom.” P131 identified their work environment as positive: “I work in the field of vocational rehabilitation so [I] interact with more people who have a more nuanced understanding of disability than the general population.” However, P165 offered an alternate view, noting that “many microaggressions are more insidious or come from within the disabled community.”

Impact of Microaggressions/Ableism on Mental Health/Wellness
     Ten participants (9%) expressed how microaggressions and ableism experiences have impacted their mental health and wellness. P172 stated, “I struggle with my mental wellness and I have been hospitalized for severe depression that manifests from a combination of my disability and situations that are overwhelming.” P157 expressed a similar combination effect of having a disability and being “ostracized” by others: “The combination is very heavy on my heart and leaves me feeling incredibly alone.”

P159 expressed feeling “pathetic and weak. Sometimes I feel useless and disgraced. Most of the time I feel dumb and stupid.” P103 added additional impacts while acknowledging the differences between their experiences and those of their colleagues of color: “None of these [microaggressions] were overt, but all contributed to stress and frustration and generalized anxiety. I have seen much worse with coworkers of color and disabled Black and Brown folks in my community.”

P126 admitted that completing the study survey “evoked difficult memories.” Additionally, this participant described the turmoil and cognitive dissonance they experience:

I’m reminded taking this survey of the inner conflict with identifying as disabled. Is my disability qualifying enough, will I be rejected? I felt hints of defensiveness emerge, like imposter syndrome. I also recognize that I desire to be abled and that keeps the conflict churning.

Microaggression Experiences Are Different Depending on Visibility of Disability
     Six participants (6.6%) spoke to how individuals with hidden disabilities experience microaggressions differently than individuals with visible/apparent disabilities. P141 asserted that “because my disabilities are hidden, I don’t hear many microaggressions regarding me,” and P183 corroborated that microaggressions are “different the more severe and obvious the disabilities are.”

P146 suggested that “invisible disabilities offer up a whole different category of microaggressions than those with visible disabilities,” and P151 added that “hidden disabilities is [sic] a double edged sword,” highlighting both the privilege and the dismissiveness hidden disabilities can bring. P150 emphasized the privilege of others not knowing about their disability: “In some ways, this benefits me because I’m not associated with the stigma of a disability.”

Internalized Ableism
     A small number of participants (n = 4) expressed comments that were consistent with Internalized Ableism. Internalized Ableism includes believing the stereotypes, myths, and misconceptions about PWD, such as the notion that all disabilities are visible and that PWD cannot live independently, and it can manifest as beliefs about their own disability or others’ disabilities. One manifestation of Internalized Ableism is when a PWD expresses that another’s disability is not real or true compared to their own disability. For example, P112 stated:Every time I go out I have great difficulty finding available accessible parking. I watch & people using the spots are walking/functioning just fine. Sick of hearing about ‘hidden disability.’ I think the majority are inconsiderate lazy people.”

Another manifestation of Internalized Ableism can be when PWD deny the existence of ableist microaggressions. P183 shared:

I don’t think that most people have microaggressions toward PWD. Maybe that’s different the more severe and obvious the disabilities are. It tends to be older people like 60s or 70s that treat me differently period it seems like the younger generation just sees most of us as people not disabled people. And I also think the term ableist separates PWD and people without. If we don’t want to be labeled, we shouldn’t label them.

Microaggressions Include Identities Other Than Disability
     For this final theme, four participants (4.44%) spoke to the complexity related to microaggressions when a PWD has additional nondominant cultural identities. P167 expressed the compounding effect: “I have multiple minoritized identities—the intersection leads to more biases.” P161 articulated the inherent confusion when one has multiple nondominant identities: “I do not know whether I am treated in the ways I indicated because of my disabilities or because I am a person of color.” These quotes highlight the inherent increase and subsequent impact on PWD who have more than one nondominant cultural identity.


The purpose of our analysis was to illuminate participants’ lived experiences with ableist microaggressions that were important to them. We revealed contextual information about participants’ experiences that aligned with the AMS subscales (i.e., Minimization, Denial of Personhood, Otherization, and Helplessness). Although prior qualitative ableist microaggression studies (e.g., Coalson et al., 2022; Eisenman et al., 2020; Olkin et al., 2019) grounded their research in Keller and Galgay’s (2010) eight categories rather than in Conover et al.’s (2017a) four subscales, it is fair to say that our findings substantiate other researchers’ findings because Conover et al.’s four subscales were devised based on Keller and Galgay’s findings.

While the corroboration of prior research findings based on the AMS subscales is illustrative and essential, the crucial findings from this study lie in the unique themes that arose from the in vivo coding process (i.e., Fortitude/Resilience/Coping, Contextual Factors, Impact of Microaggressions/Ableism on Mental Health/Wellness, Microaggression Experiences Are Different Depending on Visibility of Disability, Internalized Ableism, and Microaggressions Include Identities Other Than Disability). These themes introduce both novel and less-explored aspects of disability and of ableist microaggressions.

Fortitude/Resilience/Coping is a unique theme. Participants described how they became stronger and persevered despite microaggressive experiences. Eisenman et al. (2020) were the first to identify microaffirmations within ableist microaggressions research and Coalson et al. (2022) found that their participants perceived benefits that came from microaggressive experiences; both are important contributions. However, both instances of seeming positives related to ableist microaggressions in these studies are framed within the context of how others acted toward PWD rather than the autonomous choices and personal development of the person with the disability in the face of adversity. Our findings demonstrate PWD’s abilities—both innate qualities and learned skills—that rendered life-giving fortitude, resilience, and coping in which they are personally empowered and persevere despite external stimuli; they are not dependent upon whether others act appropriately. This is a key finding for counselors because they have the ability to create a therapeutic environment in which PWD can process, develop, and refine their fortitude, resilience, and coping further, acknowledging that PWD have these skills already.

Unsurprisingly, some participants spoke to the impact of ableist microaggressions and ableism on their mental health and wellness; these impacts included depression, loneliness, stress, frustration, and feeling “pathetic and weak.” What was surprising is that only 9% of the sample spoke to this impact directly, given how well-documented the harmful mental health effects of microaggressions are (Sue & Spanierman, 2020). This seeming underrepresentation of mental health ramifications amongst participants led us to wonder, based on the high percentage of participants (30%) who endorsed Fortitude/Resilience/Coping, whether this specific sample had a uniquely high ability to cope with adversity as compared to the overall disability population or if it is possible that ableist microaggression experiences have begun to decrease. While we are unable to answer these questions directly as part of this study, we posit three considerations: (a) microaggressions continue to have a negative effect on some PWD and need to be screened for and attended to within the counseling process; (b) screening for and helping clients with disabilities name, develop, or refine coping, fortitude, and resilience can prove beneficial; and (c) it is worthwhile to continue to work to reduce microaggressive behaviors in every way possible.

Although we had an independent theme in which participants indicated the differences between apparent and hidden disabilities, the participant quotes within every theme illustrate these differences as well. For instance, within the Minimization theme, P137 highlighted that those with hidden disabilities may be told that “personal responsibility” is the cause of their disability, while P105 and P109 spoke to having to “prove” their apparent disability to others, including family. Having to prove one’s disability or not being believed tracks with several other researchers’ findings including Olkin et al. (2019), who found that medical professionals did not believe PWD’s symptoms and experiences. The Helplessness theme revealed differences such as P129 receiving unsolicited advice once people learn of their hidden disability; however, this theme revealed similarities, too. Participants with both apparent and hidden disabilities experienced others acting on their behalf without their consent.

The Microaggression Experiences Are Different Depending on Visibility of Disability theme may explain why a higher percentage of participants with hidden disabilities or those who have both hidden and apparent disabilities participated in the qualitative portion of the study than those with apparent disabilities, which was the higher percentage in the quantitative part of the study. By definition, microaggressions can leave those who experience them questioning whether what they experienced was real, and this could be compounded when PWD have hidden disabilities; these participants may have needed to express their experiences more than those with apparent disabilities. While our data demonstrate that having a hidden disability may be a protective factor from experiencing ableist microaggressions, their disability experience often can be overlooked or ignored, resulting in a form of minimization that is both congruent with and distinct from the Minimization subscale definition.

Participants made a case for how Contextual Factors, defined as relational, situational, and/or environmental components, impact microaggression experiences. Implicitly, several authors spoke to what we have named as Contextual Factors (e.g., Coalson et al., 2022; Eisenman et al., 2020; Miller & Smith, 2021), yet the specificity and nuance participants provided in this study warranted a distinct theme. Relationally, participants noted that whether the perpetrator knew them and if there was a relational power differential between them and the perpetrator (e.g., doctors or counselors vs. family member or neighbor) makes a difference. Damningly, P152 stated that “the worst comments” they have received “have come from mental health therapists.” Participants noted, too, that work environments, life stage, the type of assistive technology they are using at the time, and being part of the disability community can all be impactful in both affirming and deleterious ways. It is imperative that counselors assess and understand thoroughly each client’s specific contextual factors so they can identify ways in which clients have internal and external resources and support, as well as areas in which they may want strategies, support, resources, and, potentially, advocacy intervention.

A small number of participants (n = 4) spoke to Internalized Ableism. Although this was a less robust theme, it was important to report because it adds to professional knowledge about what some clients with disabilities might believe and express during counseling sessions. We defined Internalized Ableism as participants expressing stereotypes, myths, and misconceptions about PWD that can manifest as beliefs about their own disability or the disabilities of others. One participant expressed disdain for hidden disabilities and expressed disbelief about others’ needs to use parking for disabled persons, while another participant questioned whether most PWD experience ableist microaggressions. While our study findings are not congruent with these statements, counselors must take clients’ expressions seriously, work to understand how clients have developed these beliefs, and seek to understand their impact on the client who is stating them.

Finally, four participants indicated that Microaggressions Include Identities Other Than Disability. Given the high percentage of the sample that had multiple nondominant identities, it is curious that so few participants spoke to this phenomenon. However, we theorize that this may have to do with identity salience (Hunt et al., 2006) and the fact that this was a study about ableist microaggressions. For the participants who spoke to this theme, the important features they reported were the compounding effect of microaggressions when one has multiple nondominant identities and the inherent confusion that results from microaggressive experiences, particularly when one has multiple nondominant identities. Again, counselors must screen for and be prepared to address the complexity and the impact of ableist microaggressions based on each client’s unique identities and experiences.

Implications for Practice
     The study findings illustrate the ubiquitous, troubling, and impactful nature of ableist microaggressions. These findings expose many counselors, supervisors, and educators to a world they may not know well or at all, while for others, these findings validate experiences they know all too well personally and professionally. We began this article with a quote from the pre-Socratic philosopher Heraclitus: “Day by day, what you choose, what you think, and what you do is who you become.” This quote captures the charge we are issuing to counseling professionals: It is time to take action to become counseling professionals who think as, act as, and are disability-affirming professionals. The task at hand is for each counseling professional to decide what steps to take next to strengthen their disability-affirming identity based on their current awareness, knowledge, and skill level, as well as how they can enact their disability-affirming identity based on their professional roles.

Fundamentally, disability-affirming professionals validate, support, encourage, and advocate for and with PWD consistently throughout their professional activities. For many, this begins with developing their awareness and knowledge, followed later by their skills. Based on the findings presented in this article, we suggest counseling professionals engage in self-reflexivity by examining the ways in which they have unwittingly adopted the dominant discourses about disability, what they believe about the abilities and lives of PWD, how they understand disability within the context of other nondominant identities, and the ways in which they have participated in perpetuating ableist microaggressions. Without engaging in disability self-awareness development, professionals risk conveying ableist microaggressions to clients that can result in early termination, impede the therapeutic relationship, and/or inflict additional psychological harm (Sue & Spanierman, 2020). For example, counselors may assume that clients with disabilities have diminished social–emotional learning skills compared to clients without disabilities and initiate formalized assessment based on this assumption. While counselors should be attuned to all clients’ social–emotional skills, it can be damaging to PWD’s sense of self and the counseling relationship to assume their social–emotional learning skills are deficient rather than assessing how environments are not conducive to PWD’s social–emotional needs (Lindsay et al., 2023).

Counselors’ self-reflexive process is meant to foster self-awareness; to better equip counselors to recognize ableist microaggressions in clients’ stories when they occur in personal, training, and professional environments; and for them to avoid unintentionally communicating ableist microaggressions in their practice. To start this process, we encourage counselors to question whether any of the study findings rang true, whether as someone who has experienced ableist microaggressions or as one who has perpetrated them, and to ascertain whether their attitudes and beliefs about PWD differ based on the visibility of disability. Additionally, we proffer that counselors who engage in self-reflective activities, such as the ones mentioned above, and those who learn more about PWD’s lives and experiences are more apt to create a plan to work through any negative attitudes or biases they have and, in turn, refine their skills so they are more disability-affirming in their practice. Counselors who engage in these processes will benefit those they serve, whether clients, students, or supervisees.

This study represents only a slice of the microaggression experiences of PWD. We concur with Rivas and Hill (2023) that counselors must adopt an evolving commitment to develop disability counseling effectiveness. Ways that counselors can take steps toward developing their disability-affirmative counselor identity and effectiveness include familiarizing themselves with and applying the American Rehabilitation Counseling Association (ARCA) disability competencies (Chapin et al., 2018); reading additional studies (e.g., Olkin et al., 2019; Peters et al., 2017); listening to podcasts (e.g., Swenor & Reed, n.d.); reading blogs and books (e.g., Heumann & Joiner, 2020); and watching shows and movies that highlight PWD’s experiences, microaggressive and otherwise—PWD are telling their stories and want others to learn from them.

Within the relational context, no matter one’s professional roles, it is important to be prepared to attend to the interaction of identity constellations within professional relationships and the power dynamics that are present (Ratts et al., 2016). Broaching these topics initially, including ability status and similarities and differences with our experiences, is a helpful start; however, this is the beginning of the process, not the entire process. Accordingly, clinicians must continually assess PWD’s contextual factors and their impact, lived experiences of their multiple identities, resilience, fortitude, and coping skills. To do so, clinicians must first create space for clients to process their microaggression experiences through actively listening to their stories; allowing PWD to openly express their frustrations, anger, or other emotions; and validating their experiences using advanced empathy. In other words, it is critical not to dismiss such topics nor unilaterally make them the presenting problem—balance is needed to attend to microaggression experiences appropriately. Essentially, counselors need to guide clients to discern the impact and to identify what they need rather than doing it for them, and to be ready, willing, and able to advocate with and on behalf of clients. All advocacy actions must be discussed with clients so as to center their autonomy.

Clients’ resiliencies and strengths must be fostered unceasingly. It is not uncommon for clients who have experienced ableist microaggressions to feel diminished and worthless and to question their purpose. Counselors must prioritize assisting clients in naming their strengths and telling stories about how they have developed resiliencies, and they must encourage clients to draw on both when facing adversity—particularly ableist microaggressions. While the goal is to eradicate ableist microaggressions, we must reinforce with clients that they are armed with tools to safeguard against ableist microaggressions’ impact and that they can seek trusted support when they need it.

As we move forward into the future as disability-affirming counseling professionals, counselor educators and supervisors have a specific charge to include disability status and disability/ableist microaggressions as part of their professional endeavors when working with students and supervisees. For many, the aforementioned recommendations likely apply because they, too, did not receive education about disability and disability microaggressions (Deroche et al., 2020). This is a setback, but not a limitation. Counselor educators and supervisors are continual learners who seek additional awareness, knowledge, skills, and advocacy actions to positively impact their work with counselors-in-training. Webinars, disability-specific conference sessions, and engaging with community disability organizations are helpful ways to start, and we recommend counselor educators and supervisors engage in the same self-examination strategies mentioned above to begin combating any biases they may hold about PWD. More specifically, counselor educators and supervisors can introduce and teach the ARCA disability competencies to trainees and supervisees, deliberately integrate self-exploration activities regarding disability into coursework, direct trainees and supervisees to inquire about ability status in intake and assessment procedures, and use cultural broaching behaviors to model appropriate use with clients (Deroche et al., 2020).

Limitations and Future Research

There are important limitations to consider to contextualize the study findings. The data used in this analysis were the result of one open-ended prompt as part of a larger quantitative study. Although participants offered robust and illustrative responses, it is a significant limitation that no follow-up questions were asked. Additionally, because the study utilized the AMS (Conover et al., 2017b), we analyzed data using the AMS subscales. While this was an appropriate choice given the context, it limited our ability to compare our findings with other qualitative studies that used Keller and Galgay (2010) to explain their findings.

We recommend that future research investigates the unique themes from this study in more detail to ascertain whether they are applicable to the larger PWD population. We suggest that focus groups combined with individual interviews may help to tease out nuances and could potentially lead to developing theory related to ableist microaggressions and best practices that will support PWD. Finally, we propose that more in-depth intersectionality research would benefit PWD and the professionals who serve them. The confounding nature of microaggressions combined with individuals’ unique identity compositions that often include both nondominant and dominant identities can make this type of research challenging, yet both are the reality for many PWD and this research is therefore needed.


Ableist microaggressions are ubiquitous and damaging to PWD. Through our analysis, we found that participants’ experiences corroborated prior researchers’ findings related to established ableist microaggression categories and added new knowledge by introducing six novel themes. We envision a disability-affirmative counseling profession and offered concrete recommendations for clinicians, supervisors, and counselor educators. Together, we can create a reality in which all PWD who seek counseling services will experience relief, validation, and empowerment as we work to create a society that provides access to all.


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



Boyatzis, R. E. (1998). Transforming qualitative information. SAGE.

Chapin, M., McCarthy, H., Shaw, L., Bradham-Cousar, M., Chapman, R., Nosek, M., Peterson, S., Yilmaz, Z., & Ysasi, N. (2018). Disability-related counseling competencies. American Rehabilitation Counseling Association (ARCA) Task Force on Competencies for Counseling Persons with Disabilities.

Coalson, G. A., Crawford, A., Treleaven, S. B., Byrd, C. T., Davis, L., Dang, L., Edgerly, J., & Turk, A. (2022). Microaggression and the adult stuttering experience. Journal of Communication Disorders, 95, 106180.

Conover, K. J., Israel, T., & Nylund-Gibson, K. (2017a). Development and validation of the Ableist Microaggressions Scale. The Counseling Psychologist, 45(4), 570–599.

Conover, K. J., Israel, T., & Nylund-Gibson, K. (2017b). Ableist Microaggressions Scale (AMS) [Database record]. APA PsycTESTS.

Dávila, B. (2015). Critical race theory, disability microaggressions, and Latina/o student experiences in special education. Race, Ethnicity, and Education, 18(4), 443–468.

Deroche, M. D., Herlihy, B., & Lyons, M. L. (2020). Counselor trainee self-perceived disability competence: Implications for training. Counselor Education and Supervision, 59(3), 187–199.

Deroche, M. D., Ong, L. Z., & Cook, J. M. (2024). Ableist microaggressions, disability characteristics, and nondominant identities. The Professional Counselor, 13(4), 404–417.

Eisenman, L. T., Rolón-Dow, R., Freedman, B., Davison, A., & Yates, N. (2020). “Disabled or not, people just want to feel welcome”: Stories of microaggressions and microaffirmations from college students with intellectual disability. Critical Education, 11(17), 1–21.

Heumann, J., & Joiner, K. (2020). Being Heumann: An unrepentant memoir of a disability rights activist. Beacon Press.

Hunt, B., Matthews, C., Milsom, A., & Lammel, J. A. (2006). Lesbians with physical disabilities: A qualitative study of their experiences with counseling. Journal of Counseling & Development, 84(2), 163–173.

Keller, R. M., & Galgay, C. E. (2010). Microaggressive experiences of people with disabilities. In D. W. Sue (Ed.), Microaggressions and marginality: Manifestation, dynamics, and impact (pp. 241–268). Wiley.

Lindsay, S., Fuentes, K., Ragunathan, S., Lamaj, L., & Dyson, J. (2023). Ableism within health care professions: A systematic review of the experiences and impact of discrimination against health care providers with disabilities. Disability and Rehabilitation, 45(17), 2715–2731.

MacQueen, K. M., McLellan, E., Kay, K., & Milstein, B. (1998). Codebook development for team-based qualitative analysis. Cultural Anthropology Methods, 10(2), 31–36.

Miller, R. A., & Smith, A. C. (2021). Microaggressions experienced by LGBTQ students with disabilities. Journal of Student Affairs Research and Practice, 58(5), 491–506.

Norwood, M. F., Lakhani, A., Hedderman, B., & Kendall, E. (2022). Does being psychologically resilient assist in optimising physical outcomes from a spinal cord injury? Findings from a systematic scoping review. Disability and Rehabilitation, 44(20), 6082–6093.

Olkin, R., Hayward, H., Abbene, M. S., & VanHeel, G. (2019). The experiences of microaggressions against women with visible and invisible disabilities. Journal of Social Issues, 75(3), 757–785.

Ordway, A. R., Johnson, K. L., Amtmann, D., Bocell, F. D., Jensen, M. P., & Molton, I. R. (2020). The relationship between resilience, self-efficacy, and employment in people with physical disabilities. Rehabilitation Counseling Bulletin, 63(4), 195–205.

Patel, D. R., & Brown, K. A. (2017). An overview of the conceptual framework and definitions of disability. International Journal of Child Health and Human Development, 10(3), 247–252.

Perrin, P. B. (2019). Diversity and social justice in disability: The heart and soul of rehabilitation psychology. Rehabilitation Psychology, 64(2), 105–110.

Peters, H. J., Schwenk, H. N., Ahlstrom, Z. R., & Mclalwain, L. N. (2017). Microaggressions: The experience of individuals with mental illness. Counselling Psychology Quarterly, 30(1), 86–112.

Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48.

Rivas, M., & Hill, N. R. (2023). A grounded theory of counselors’ post-graduation development of disability counseling effectiveness. Journal of Counselor Preparation and Supervision, 17(1).

Rolón-Dow, R., & Davison, A. (2018). Racial microaffirmations: Learning from student stories of moments that matter. Diversity Discourse, 1(4), 1–9.

Rolón-Dow, R., & Davison, A. (2021). Theorizing racial microaffirmations: A critical race/LatCrit approach. Race Ethnicity and Education, 24(2), 245–261.

Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–286.

Sue, D. W., & Spanierman, L. (2020). Microaggressions in everyday life (2nd ed.). Wiley.

Swenor, B., & Reed, N. (Hosts). (n.d.). Included: The disability equity podcast [Audio podcast]. Johns Hopkins University Disability Health Research Center.

Jennifer M. Cook, PhD, NCC, ACS, LPC, is an associate professor at the University of Texas at San Antonio. Melissa D. Deroche, PhD, NCC, ACS, LPC-S, is an assistant professor at Tarleton State University. Lee Za Ong, PhD, LPC, CRC, is an assistant professor at Marquette University. Correspondence may be addressed to Jennifer M. Cook, University of Texas at San Antonio, Department of Counseling, 501 W. Cesar E. Chavez Blvd, San Antonio, TX 78207,