Nov 29, 2017 | Volume 7 - Issue 4
Angelica M. Tello, Nancy E. Castellon, Alejandra Aguilar, Cheryl B. Sawyer
The United States has recently seen a significant increase in the number of unaccompanied minors from the Northern Triangle of Central America (i.e., El Salvador, Honduras, and Guatemala). These children and youth are refugees fleeing extreme poverty and gang violence. This study examined the narratives of 16 refugees from the Northern Triangle who arrived in the United States as unaccompanied minors. In particular, the purpose of this study was to gain awareness of the journey experienced by unaccompanied refugee minors from their countries of origin to the United States. Thematic analysis was used to analyze the participants’ narratives, and three primary themes emerged: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States. Implications for counselors and areas for future research are discussed.
Keywords: unaccompanied minors, refugees, Central America, Northern Triangle, mental health
Displaced refugees are a worldwide crisis. The United Nations High Commissioner for Refugees (2015) reported there are 21.3 million refugees worldwide, and half are under the age of 18. Although much attention is given to the refugee crisis in Europe and the Middle East, the United States has recently seen a significant increase in unaccompanied refugee minors from the Northern Triangle of Central America (Sawyer & Márquez, 2017). These are children and youth from Honduras, Guatemala, and El Salvador who are traveling alone and crossing the Mexican border into the United States without legal authorization (Chen & Gill, 2015; Sawyer & Márquez, 2017; Stinchcomb & Hershberg, 2014).
Unaccompanied minors who are apprehended by immigration officials from the Department of Homeland Security (DHS) are transferred to the Office of Refugee Resettlement (ORR) for care (ORR, 2016). ORR (2016) reported that in their first nine years, they annually served an average of 7,000 to 8,000 unaccompanied minors. In 2012, ORR observed their first increase in numbers; services were provided to 13,625 unaccompanied children and youth (ORR, 2016). By 2014, there was a drastic increase in the number of unaccompanied minors arriving to the United States (Androff, 2016; DHS, 2016; ORR, 2016). DHS reported that 68,541 unaccompanied children and youth from Central America were apprehended at the southern border (DHS, 2016). There also was a 117% increase in the number of unaccompanied children under the age of 12 (Krogstad, Gonzalez-Barrera, & Lopez, 2014).
Although there has been a decrease in the number of unaccompanied minors entering the United States in the last few years, the numbers are still quite large. In 2016, 59,692 unaccompanied children and youth were apprehended, and 33% were female (ORR, 2016). Furthermore, the highest percentage of children were from Guatemala at 40%, followed by El Salvador and Honduras with 34% and 21%, respectively (ORR, 2016).
Unfortunately, because of recent anti-immigration rhetoric in the United States, the general public is often misinformed of the experiences of unaccompanied minors (Androff, 2016). In 2014, at the height of the surge of unaccompanied minors, various anti-immigration protests occurred in the United States against children and youth from Central America (Androff, 2016; Knake, 2014). In a protest organized in Michigan by the Michiganders for Immigration Control and Enforcement, some protesters carried rifles and handguns along with signs that read “seal the border,” “it’s law—deport,” and “no illegals” (Knake, 2014, para. 12). A major misconception is that unaccompanied minors are immigrants. However, the unaccompanied children and youth from the Northern Triangle of Central America are refugees fleeing impoverished living conditions, extreme violence from gangs and organized crime, and political instability (Androff, 2016; Chishti & Hipsman, 2015; Jani, Underwood, & Ranweiler, 2016; Sawyer & Márquez, 2017). DHS Secretary Jeh Johnson reported that over the last 15 years “far fewer Mexicans and single adults are attempting to cross the border without authorization, but more families and unaccompanied children are fleeing poverty and violence in Central America” (DHS, 2016, para. 1).
Reasons for the Increase of Unaccompanied Minors
The poverty and violence experienced by those living in the Northern Triangle of Central America have been well documented (Chishti & Hipsman, 2015; Gonzalez-Barrera et al., 2014; Jani et al., 2016; Sawyer & Márquez, 2017; Women’s Refugee Commission, 2012). Impoverished living conditions and gang violence are the major factors leading unaccompanied minors to leave Central America. Even though the journey to the United States is filled with grave danger, children are fleeing Central America because of their dire living situations.
Poverty and the Lack of Economic Opportunities
Societal inequalities and natural disasters have negatively impacted this region (International Organization for Migration [IOM], 2016; Seelke, 2016). These inequalities have led those living in the Northern Triangle to experience high rates of poverty and limited economic opportunities. Since 2012, El Salvador, Guatemala, and Honduras have been impacted by prolonged drought (IOM, 2016). This has caused immense food insecurity and has negatively affected agricultural labor. For instance, nearly 50% of the Guatemalan population has experienced chronic undernutrition (IOM, 2016). Furthermore, over half of the population in Honduras and Guatemala live in poverty: 63% and 59%, respectively (Seelke, 2016), and 40% in El Salvador (Padgett, 2014). The Northern Triangle also has high rates of youth unemployment. In El Salvador and Honduras, over 25% of youth ages 15–24 have never worked or studied (De Hoyos, Rogers, & Székely, 2016).
Violence by Gangs and Organized Crime
According to the Council on Foreign Relations, “El Salvador, Guatemala, and Honduras consistently rank among the most violent countries in the world” (Renwick, 2016, para. 4). In 2015, El Salvador’s homicide rate was the highest in the world, with 105 murders per 100,000 inhabitants (Watts, 2015). Moreover, this makes El Salvador almost 20 times more deadly than the United States (Watts, 2015). It is important to note that from 2011 to 2015, San Pedro Sula, Honduras, was identified as the most violent city in the world outside a war zone (O’Connor, 2012). From 2005 to 2010, the murder rate in Honduras more than doubled (United Nations Office on Drugs and Crime, 2011). Guatemala City also has consistently ranked as one of the most violent cities. The U.S. Department of State’s Overseas Security Advisory Council (2016) stated that “Guatemala’s homicide rate is one of the highest in the Western Hemisphere,” with 91 murders per week in 2015 (para. 2).
The high murder rates in the Northern Triangle of Central America are attributed to the maras, or gangs, in that region (Chishti & Hipsman, 2015; Jani et al., 2016; Sawyer & Márquez, 2017; Watts, 2015). The violence and murders are because of the rivalry of two prominent gangs: the Mara Salvatrucha, also known as MS-13, and Barrio 18 (Sawyer & Márquez, 2017; Seelke, 2016; Watts, 2015). These gangs were able to flourish in the Northern Triangle because of weak government and political instability in the region (Sawyer & Márquez, 2017). From the 1980s into the early 1990s, there was a deadly civil war in El Salvador between the government and the Martí National Liberation Front, a Salvadorian political party (Sawyer & Márquez, 2017). From 1960 to 1996, Guatemala suffered from a 36-year civil war between civilian farmers who lost land and voting rights and government military forces (Sawyer & Márquez, 2017). Furthermore, Honduras experienced a military coup in 2009, which led the government to suspend freedom of assembly and the press and authorize excessive force to silence opposition (Sawyer & Márquez, 2017). As the countries began to rebuild after these periods of political unrest, gangs in this region were able to go unchecked.
Gangs in Central America were able to gain control in part because of the drug demands of the United States. These gangs assist in the transportation of cocaine and marijuana moving from South America into Mexico, and eventually the United States (Sawyer & Márquez, 2017; Seelke, 2016; Watts, 2015). However, the Central American gangs are not the major narco-cartel suppliers, so they have relied on robbery, extortion, kidnapping, human trafficking, and weapons smuggling for additional sources of income (Seelke, 2016; Watts, 2015). The extortions have impacted residents, bus and taxi drivers, and general business owners (Seelke, 2016; Watts, 2015). For instance, in the El Salvadorian city of San Salvador, gangs demand residents pay “war taxes,” and those that do not pay face harassment and violence (Ribando, 2007, p. 4).
The gangs actively target children and youth as young as 7 or 8 years old for recruitment (Sawyer & Márquez, 2017). Moreover, the gangs use coercive and violent means, such as kidnapping, extortion, and murder, to force families to “give up their children” (Jani et al., 2016, p. 1196). In El Salvador, gangs have even targeted children at schools, resulting in low school attendance rates (Women’s Refugee Commission, 2012). On the other end, some youth become susceptible to gang recruitment because of high unemployment and absence of family influences (Farah, 2016). Nevertheless, the violence and intimidation perpetuated by gangs are major push factors leading children and youth to flee Central America. The exposure to violence also can have an impact on the mental health of unaccompanied minors.
Mental Health Needs of Unaccompanied Refugees
Although there is a limited understanding of the mental health needs of unaccompanied minors from the Northern Triangle of Central America, researchers have documented the common mental health needs of refugees. Because many refugees have been exposed to traumatic events and violence in their countries of origin, they experience higher rates of mental health issues, such as post-traumatic stress disorder (PTSD), depression, and emotional and behavioral problems (Bronstein & Montgomery, 2011; Karaman & Ricard, 2016; Kirmayer et al., 2011). Mental health needs do not solely stem from the trauma exposure experienced by refugees pre-migration. Many refugees also experience trauma and uncertainties during their migration and post-migration resettlement that negatively impact their mental health (Bronstein & Montgomery, 2011; Karaman & Ricard, 2016; Kirmayer et al., 2011).
According to a recent study conducted by Keller, Joscelyne, Granski, and Rosenfeld (2017), Central American refugees from El Salvador, Honduras, and Guatemala have “significant mental health symptoms” because of the violence they experienced (p. 1). Of their sample of 234 participants, 204 experienced trauma in their countries of origin, 182 fled because of violence concerns, and 166 were afraid to return home. Moreover, rates of depression and PTSD were high among those from the Northern Triangle: 32% reported clinically significant PTSD symptoms and 24% had major depressive disorder symptoms (Keller et al., 2017). Similar findings were echoed in a study that examined the mental health needs of Guatemalan refugees living in Mexico (Sabin, Lopes Cardozo, Nackerud, Kaiser, & Varese, 2003). The researchers surveyed 170 participants, and all reported at least one traumatic event, with a total of 1,230 reported traumatic events (e.g., being close to death, friend or family member massacred, witnessing the disappearance of others; Sabin et al., 2003). From these participants, 11.8% met symptom criteria for PTSD, 54.4% had anxiety symptoms, and 38.8% revealed depression symptoms (Sabin et al., 2003).
Further research is needed on the mental health needs of unaccompanied minors from the Northern Triangle of Central America. The purpose of this study was to gain awareness of the journey experienced by unaccompanied minors from their countries of origin to the United States and to provide implications for counselors. Therefore, the following research question guided the study: What are the experiences of unaccompanied refugee minors from the Northern Triangle of Central America?
Method
Thematic analysis, a qualitative methodological approach, was utilized because the researchers were analyzing written narratives. Thematic analysis, unlike content analysis, provides a rich and detailed description of the data (Vaismoradi, Turunen, & Bondas, 2013). This research study was approved by the researchers’ institutional review board.
Participants
The researchers analyzed the narratives of 16 participants. All the participants entered the United States as unaccompanied minors from the Northern Triangle of Central America (i.e., El Salvador, Honduras, and Guatemala) and were receiving assistance through a shelter in the Southern region of the United States. Part of the assistance included counseling services offered by a counseling graduate program affiliated with the researchers. After gaining signed consent forms, the participants and their appointed legal guardians received individual counseling sessions in Spanish with bilingual counselors-in-training (CITs). Three of the participants were female, and 13 were male. Ten of the participants were from Honduras, three were from Guatemala, and three were from El Salvador. Participants’ ages ranged from 10 to 23. Although some of the participants were over 18 years of age at the time of the study, they arrived in the United States as unaccompanied minors.
Data Collection
The data was collected during the counseling process. The CITs involved had at least one semester of supervised counseling experience. They also had completed all foundational counseling courses in their degree plan, including counseling theories, multicultural counseling, assessment, diagnosis, human growth and development, crisis intervention, counseling skills, and group counseling. At the time of the study, the CITs were enrolled in a bilingual counseling course and received information on the counseling needs of unaccompanied refugee minors.
Each CIT was assigned a participant and completed three to 18 hours of individual counseling sessions. The hours varied depending on the participants’ availability. Because the participants were exposed to violence in their countries of origin and the journey to the United States, CITs utilized basic relaxation skills, trauma-focused cognitive behavioral therapy (TF-CBT), and expressive counseling techniques to help the participants process their experiences. Upon conclusion of the counseling sessions, each participant organized a digital storybook that illustrated and discussed their journey to the United States. The storybooks were created on iPads using Microsoft PowerPoint. The participants received assistance from their CITs on utilizing the iPad and writing the content for each page of their book. The books ranged from five to 26 pages. After eliminating all identifying information, the content of the books was provided to the researchers by the CITs. The content was then translated from Spanish to English, and two external auditors provided language translation verification.
Data Analysis
The data were analyzed using the thematic analysis approach outlined by Braun and Clarke (2006). First, the researchers familiarized themselves with the data by reading and re-reading each participant’s book content. Key ideas were documented during this time. Next, a systematic approach was taken in reviewing the data and identifying codes. In particular, a “data-driven” approach was used to code instead of a “theory-driven” approach (Braun & Clarke, 2006, p. 88). These codes were then grouped into potential themes based on shared meanings. The researchers also reviewed and discussed the themes to ensure they represented the data. This process allowed for the refining of each specific theme. External auditors then reviewed the themes and reported that the themes reflected the participants’ experiences. The participants discussed their journey from their countries of origin to the United States. Therefore, the themes reflect what occurred on their journey. Based on these themes, the researchers provide implications for counselors and discuss mental health issues.
Results
Based on the analysis of the participants’ narratives, the researchers identified three primary themes and 11 subthemes. The primary themes were: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States. Each theme is described in the following section. Pseudonyms were selected for each participant to protect their privacy.
Reasons for Leaving Central America
All the participants discussed factors that contributed to them fleeing their countries of origin. Three subthemes fell under the primary theme of what led the participants to leave Central America: (a) to financially help family, (b) to escape gang violence and death, and (c) powerlessness. It is important to note that these subthemes are closely related. The gangs in the Northern Triangle of Central America were a result of the extreme poverty in that region, and they also contributed to the poverty experienced by the participants.
Financially help family. Many of the participants experienced extreme poverty in their home countries. Enrique shared how he grew up in a “house made out of sticks, mud, and rocks” and how his family “melted fat in order to eat.” When he was 10 years old, his father was killed by a gang, and he stopped attending school to provide for his family. He left for the United States with the support of his mother because it was difficult to find a job and the country’s economy was unstable because of the gangs. Many of the participants echoed these sentiments. For instance, Federico also shared that “poverty, delinquency, and lack of work opportunities” led him to leave his native country for “a more promising future for myself and my family.”
Escape violence and death. All the participants fled their home countries in order to escape violence and death. Federico provided a detailed account of how the maras, or gangs, in his native country recruited children as new members. If someone did not join, the gang members would kidnap, rape, or kill his or her family members. This led Federico and many of the participants to flee their countries; they felt there was no other option to escape the violence.
Some participants left their native countries because gang members threatened to kill them. Brenda lost her parents because of gang violence and was living with her aunt and uncle. Brenda fled to the United States shortly after this incident: “My aunt received a phone call from somebody who said that my sister and I were easy targets. . . . And if they were not paid a certain amount, we [participant and her sister] would be hurt.”
Powerlessness. Another subtheme that emerged was powerlessness. Some of the participants were homeless because of the extreme poverty and violence. Additionally, they felt alone and had no family ties left in their home countries. These participants felt powerlessness regarding what occurred in their lives and fled to the United States to gain a sense of control. Armando shared feeling powerless after his mother died from a heart attack when he was 14 years old. Afterward, he lived with his brothers for 2 years, but they did not support him. Armando’s friend then encouraged him to flee to the United States because he was on his own.
Journey to the United States
In their narrative books, the participants discussed what occurred on their journeys to the United States. The subthemes that fell under this primary theme were: (a) mode of journey, (b) physical pain, (c) emotional pain, and (d) help from others.
Mode of journey. Participants either arrived by riding above trains or through the assistance of a smuggler, also known as a coyote. Carlos tried multiple times to come to the United States and primarily used the train. His first attempt was at 6 years old, but he was unable to complete the journey. The second time Carlos fled Central America, he “came aboard the train of death.” The train was often referred to by participants as la bestia, or the beast. Several participants shared these experiences. For instance, Enrique made three attempts to leave Central America starting at 11 years old. His journey took him 8 months to arrive in the United States. Other participants arrived in the United States through smugglers. Cristobal described how his parents saved money so they could pay a coyote to bring him to the United States.
Physical pain. The participants provided various accounts of physical and emotional trauma experienced on their journey to the United States. Several of the participants reported being beaten and robbed in Mexico when their trains would stop at various points. To find food, the refugees had to get off the train. Federico discussed how traveling alone led one to be vulnerable to “food, water, and clothes predators.”
Some participants described not knowing what to expect on their path to the United States; they were not prepared for what lay ahead while on the train or by foot. Federico wrote: “We knew nothing about the journey, knew no landmarks, and knew nothing about the path that could help us plan ahead.” Damian wrote about the freezing temperatures he was not prepared for when the train reached mountainous terrain. He was traveling with two other boys, and they were only wearing t-shirts and pants. He described how he felt immense pain from the freezing weather and worried that he was “dying from the cold.” Damian felt fortunate that he was traveling with someone who told him they needed to take off their clothes and use their body heat to keep warm.
Other participants provided accounts of being physically injured on their journey because of days of walking in desert terrain. Brenda recalled the injuries and pain caused to her feet: “It took us 8 days to get to our stopping point. I remember that my shoes had peeled the soles of my feet, and my toenails had fallen off.” Feet being severely damaged from walking was a common experience shared by the participants.
Fernando began his journey at 10 years old and recounted the injuries he received from the train and walking nonstop for 2 days as he approached the Mexico–United States boarder: “My arms were bandaged from having been hurt on the train. . . . I saw the body of a man floating in the river. I wondered if it was the body of my father.” Fernando’s accounts illustrate the nature of the physical and emotional pain the participants experienced. Not only was Fernando physically hurt on his journey, but he also carried the emotional or psychological wounds of witnessing death at a young age. In his book, Fernando also wrote about seeing a man’s body being dismembered after accidentally falling from the train.
Emotional pain. All the participants were exposed to and witnessed trauma on their journey to the United States. They were exposed to physical and sexual assaults and death. For instance, riding above the train was very dangerous. Participants provided accounts of people being sucked under the train as they tried to jump on. Enrique wrote about seeing a girl die trying to get on the train. Federico stated that the following events impacted him the most on his journey: “(I) witnessed a person being shot to death, the raping of women while family members were forced to witness this, witnessing a person being cut to pieces by the train, and seeing pieces of human bodies alongside the railroads.” These were not isolated events; all the participants reported at least one such traumatic situation.
Damian wrote how he “felt frustrated and powerless” after seeing a girl being raped by a gang of three or four men; the girl’s brother was forced to watch the sexual assault. He met the girl and her brother a few days before the sexual assault occurred. Damian was told by his cousin not to intervene or confront the rapists because he would most likely be killed or severely assaulted by the gang. Many of the participants, like Damian, noted that these memories were reoccurring, and how they often think about those whom they saw injured and sexually assaulted. Damian wrote how he wants to find the girl who was raped and explain to her why he did not intervene and that he wants to apologize. In his book, Damian listed her name and the city she was planning to arrive to in the United States.
Help from others. The last subtheme that emerged from the participants’ narratives was receiving help from others. Even though the participants experienced physical and emotional trauma on their journey to the United States, they met individuals along the way that provided assistance. Many of the participants reported struggling to find food. Ismael wrote: “I also remember good people throwing food at us because they knew we were hungry.” Damian shared how he met a “good-hearted lady” that gave him advice on evading possible harm. She told Damian to be careful about motorcycles because they were involved with “kidnapping migrants and asking their families for ransom.” Although this information caused “more real fear” in Damian, it helped him on his journey. There were several accounts of priests in Mexico helping refugees find local shelter. Enrique shared that he received help from a priest who took him to a “house of immigrants” to receive food, clothes, and shelter. These instances of support helped the refugee children and youth continue on their journey.
Life in the United States
The last primary theme related to the participants’ life in the United States. Four subthemes emerged from the participants’ narratives: (a) faith, (b) worries about the future, (c) help from others, and (d) view of self after the journey.
Faith. Some of the participants discussed how they felt God “guided” them on their journey to the United States. When they faced obstacles and harm, God protected them and provided guidance. As a result, they felt God would be present in their life in the United States. Even though they are continuing to face challenges in the United States (e.g., court hearings, financial instability), they believed God would continue to provide support. In her book, Delmy wrote that “although there might be darkness in life, there is light that always breaks through the darkness.” She then stated that her faith provides her the “light” to keep moving forward in the United States.
Worries about the future. The refugee children and young adults in the study described various worries about their future. Some participants shared worries about providing for their family. Robert echoed these sentiments; he had two jobs to help his family back home. Other participants were worried about their family’s safety in Central America. Damian described how he is worried because his “mother is sad.” She even told him that “she doesn’t want to live anymore” because of the dire situation in Central America. Damian also was worried about the safety of his younger sister.
There were worries expressed about the participants’ safety in the United States. Delmy expressed feeling alone at the detention center and “fears” that people want to harm her. Moreover, several participants expressed worries about their immigration status in the United States and being judged by American society. Jesus stated: “I hope that one day I can be accepted by the American society. I can only pray that I am not judged too harshly. I plan on continuing to help my family to have a better life.” Tomas, like many of the participants, was waiting on his court hearing. He described the uncertainty and worries of his future: “My future is uncertain. . . . I will either be deported back to my country where there is a high possibility that I can be killed, or my immigration status will become legalized in the near future.” For those that fled gang violence, being sent back to their countries of origin could be a death sentence. For Carlos, who recently gained legal status, there was worry about discrimination he might face in the United States: “Some people judge me without knowing me, even more so in this country where there is so much discrimination against immigrants. And even though I am legal, it does not mean that other people will not judge me.”
Help from others. Participants noted receiving help from individuals in the United States. The help they received provided them with hope and guidance to keep moving forward in a positive direction. In his book, Armando expressed how he allowed himself to be picked up by immigration authorities. He felt alone and did not know how he was going to survive in the United States. Armando shared that once he was detained, he received help from his assigned lawyer. She gave Armando hope that he could stay in the United States, attend school, and have a positive future. Now, Armando wants to give back to his community and help other unaccompanied minors from Central America. Damian expressed similar sentiments; he wants to help others because of the support he received from the director of a children’s shelter. The director has become a father figure to Damian and has helped him realize that he has a future.
View of self after the journey. The participants’ views of themselves after their journey was another subtheme that emerged from the participants’ narratives. For some participants, they felt their life was going nowhere—there was no hope. Tomas expressed these sentiments: “My American dream has become my nightmare. My journey here was not pleasant plus I feel helpless here because I cannot help my family in Central America. . . . I feel my life has no meaning.” Not only was Tomas’s journey filled with trauma and pain, his life in the United States was uncertain. Furthermore, he was separated from his family and unable to help them financially or provide for their safety. Other participants viewed themselves as “survivors.” Carlos finished his book with the following: “This book does not show all the pain and sacrifice that I have endured, but it is a reminder that I am a survivor.”
Discussion
This study examined the narratives of 16 refugees from El Salvador, Honduras, and Guatemala who arrived to the United States as unaccompanied minors. The data set was gathered to answer the research question: What are the experiences of unaccompanied refugee minors from the Northern Triangle of Central America? From the participants’ narratives, three primary themes emerged: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States.
There were three prominent reasons that led participants to flee their home countries in Central America. Some participants described living in poverty and leaving for the United States to financially help the family. Also, all participants discussed fleeing to escape gang violence and death. Previous literature on unaccompanied refugees from the Northern Triangle has discussed how poverty (Gonzalez-Barrera et al., 2014; IOM, 2016) and gang violence (Jani et al., 2016; Sawyer & Márquez, 2017; Seelke, 2016) are major push factors. However, participants in this study also reported feelings of powerlessness that led them to leave their home countries. Participants described feeling they did not have control of what was occurring in their lives and fleeing to the United States was a way to take hold of their future. These pre-migration worries and stressors could impact the mental health of the participants. Unaccompanied refugee minors have more traumatic stress reactions than accompanied children and non-immigrants (Bean, Derluyn, Eurelings-Bontekoe, Broekaert, & Spinhoven, 2007).
This study also provided some insight into the experiences of unaccompanied refugee minors on their journey to the United States. The participants described their mode of journey, which fell into two categories: using a coyote, or smuggler, and riding above trains. These findings were consistent with what has been documented in the literature (Sawyer & Márquez, 2017; Uehling, 2008) regarding unaccompanied refugees from Central America. Previous literature (Keller et al., 2017; Sawyer & Márquez, 2017) has focused on the living conditions of refugee minors in their home countries, which represent the push factor present in their lives in El Salvador, Honduras, and Guatemala. The participants in this research study shared the physical and emotional pain that was part of the journey to the United States. They provided detailed accounts of how they were physically assaulted, faced various injuries to their bodies because of long days of walking, and lacked the proper clothing to endure the various terrains they encountered. Furthermore, the participants also shared the emotional pain they experienced on their journey: reoccurring images from witnessing physical and sexual assaults and seeing dead bodies. These types of physical and emotional pain place unaccompanied refugee minors at greater risk of mental health problems. The exposure to trauma and stressors can lead refugees to develop depressive and anxiety disorders including PTSD (Keller et al., 2017; Sabin et al., 2003; Vervliet at al., 2014). For minors, mental health issues can significantly impair their functioning (e.g., academics; Fox, Burns, Popovich, Belknap, & Frank-Stromborg, 2004).
In the literature on unaccompanied refugees from the Northern Triangle, there was limited understanding of their experience once they arrived in the United States. The participants in this study provided some insight into these experiences. Faith was a prominent theme that emerged and has not been discussed in the literature. For many of the participants, their faith and religious views were sources of strength as they transitioned to life in the United States. Participants also gained a sense of empowerment from the help they received from various sources in the United States. Emotional support from lawyers or mentors in the community gave the participants hope to continue moving forward in a positive direction. However, many of the participants shared worries about their future. These worries were about their family members who were left back at home, their safety in the United States, and the uncertainty of their legal status. Many of the participants also were aware of the discrimination they would face in the United States.
Discrimination and prejudice have been documented as post-migration stressors for immigrants in the United States (Pumariega, Rothe, & Pumariega, 2005). Discrimination can have a negative impact on the mental health of refugees (Montgomery & Foldspang, 2008). Those who experience discrimination may exhibit stress and depressive symptoms (Stuber, Galea, Ahern, Blaney, & Fuller, 2003). The participants wondered whether discrimination would impact their ability to stay in the United States or cause them to be deported. For these participants, deportation meant being sent back to a death sentence. All of these worries and uncertainties about their future led some participants to feel they had no hope for their futures.
Along with the exposure to trauma experienced by unaccompanied minors pre-migration, they experience additional stressors post-migration in the United States. In a study conducted with unaccompanied refugee minors in Europe, there were high rates of anxiety, depression, and PTSD symptoms (Vervliet et al., 2014). In particular, high scores were rated (self-report measures: Hopkins Symptoms Checklist-37A, Stressful Life Events, Reactions of Adolescents to Traumatic Stress, and Harvard Trauma Questionnaire) for these symptoms shortly after the unaccompanied minors arrived at their host countries (Vervliet et al., 2014). Their findings dispute previous research that suggests that there is a “honeymoon” phase experienced after arrival in the host country (Tousignant, 1992; Ward, Okura, Kennedy, & Kojima, 1998). This study helps shed some light into the additional stressors experienced by unaccompanied refugee minors post-migration: worries about their future such as safety, immigration status, and being judged. Constant uncertainty about their future, coupled with the exposure of trauma in their past, might increase the anxiety, depression, and PTSD symptoms experienced by unaccompanied refugees. Obviously, counselors can play an important role in addressing the mental health needs of unaccompanied refugee minors.
Implications for Counselors
Unaccompanied refugees from Central America experience various forms of trauma in their countries of origin and on the journey to the United States (Keller et al., 2017; Sawyer & Márquez, 2017). As a result, these children and adolescents are at risk of developing PTSD and major depressive disorder symptoms (Keller et al., 2017; Sawyer & Márquez, 2017). Therefore, it is crucial that counselors working with unaccompanied refugees be informed of trauma counseling theories and interventions such as trauma-informed care (Substance Abuse and Mental Health Services Administration, 2014).
Additionally, counselors must practice multiculturally competent counseling services with this population and create a safe space for clients to process their trauma (Sawyer & Márquez, 2017). Building rapport is crucial when counseling refugees. Clients might be anxious about sharing personal information because of past experiences of mistrust (Tribe, 2002). Moreover, unaccompanied refugee minors might have culture-bound expressions of mental health symptoms (Pumariega et al., 2005). This means counselors must have an awareness of their client’s cultural upbringing. Counselors can work with “cultural consultants” who have connections with refugee communities and can assist in facilitating accurate mental health assessments (Pumariega et al., 2005, p. 591). Culturally competent counselors also need to be aware of factors that can affect the therapeutic relationship such as stigma, location, language barriers, and documentation (Pumariega et al., 2005).
Incorporating the client’s cultural values in session can assist refugees in “maintaining their equilibrium” (Tribe, 2002, p. 243). For many refugees, their sense of identity may have been threatened in their countries of origin (Tribe, 2002). For the participants in this study, arriving in the United States also meant encountering additional stressors to their sense of identity. For instance, many of the participants worried about their safety in the United States, immigration status, and judgments and discrimination from others. This study provides insight into cultural values that counselors can incorporate to help unaccompanied minors find some personal balance in the United States. Some participants shared how their faith and helping others brought personal meaning and hope for the future. Other participants held to the notion that they were survivors and that they have the skills to face struggles they will encounter in the future.
It is important for counselors working with unaccompanied refugees to understand the impact of vicarious trauma and the importance of self-care. The process of listening to the stories of refugees who have experienced trauma can in itself be very painful and cause the counselor to experience vicarious trauma. Before a counselor can begin to help a refugee client to open up about painful experiences, the counselor must consider: “Do I have the skills needed to help the client contend with the intense emotions that arise in the counseling process? Do I have the debriefing resources necessary to help myself contend with conflicting emotions?”
Although the CITs in this project had considerable experience working with refugee children as teachers and were intensely prepped for the possibility of hearing their clients discuss graphic content, they still related that the counseling process was emotionally stressful and draining. In order to help the CITs address any vicarious trauma they may have experienced from counseling unaccompanied refugees, they were debriefed after every session by their site supervisors. Many of the CITs involved in this process reported that by discussing their sessions with supervisors and with one another, they felt better able to deal with what they heard. Therefore, counselors providing services to unaccompanied refugees should regularly meet for individual or group supervision to debrief. It is important for counselors to understand the characteristics of vicarious trauma, such as cognitive distortions and changes in core beliefs (Bell, Kulkarni, & Dalton, 2003), intrusive thoughts or nightmares (Hernandez-Wolfe, Killian, Engstrom, & Gangsei, 2015), and decreased self-efficacy (Sartor, 2016). Clinical supervisors can play an important role in helping counselors to recognize and decrease symptoms of vicarious trauma (Lonn & Haiyasoso, 2016).
Engaging in self-care activities can help counselors who are providing services to clients who have experienced trauma (Lonn & Haiyasoso, 2016; Williams, Helm, & Clemens, 2012). Counselors can develop a wellness plan to help maintain self-care (Williams et al., 2012), such as participating in “spiritual or religious renewal” (e.g., prayer, meditation, yoga) or spending time in nature (e.g, camping, walking, hiking; Lonn & Haiyasoso, 2016, p. 4). Self-care activities also can include connecting with other counselors who provide services to unaccompanied refugees.
Limitations and Future Research
There were four limitations in this study. First, the study was comprised of more male than female participants. However, the sample is reflective of the population of unaccompanied minors who enter the United States in that males are more likely to enter the United States unauthorized than females (ORR, 2016). Second, the participants were asked to document their experiences in a digital storybook with the assistance of their CIT. The structure of the books could have limited what the participants shared about their experiences. Third, the digital storybooks were created after participants completed counseling. Participant reports could have been impacted by counseling. Lastly, as a result of the researchers utilizing a qualitative methodology, the findings have limited generalizability. Nevertheless, there were participants representing all three countries (i.e., El Salvador, Honduras, and Guatemala), which helps support limited transferability of the findings (Yardley, 2008).
The findings and limitations of this study provide areas for future research. The qualitative nature of the study and the findings around the emotional pain experienced by the participants opens up opportunities for conducting quantitative studies. This includes assessing if there are trauma-related diagnoses or depression and the degree to which it is experienced by unaccompanied refugees from the Northern Triangle. Moreover, the effectiveness of particular trauma-focused therapies with this population is an area that needs further exploration. For instance, TF-CBT is considered an evidence-based treatment approach with children and adolescents who have experienced trauma (Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011; Silverman et al., 2008). However, there is limited understanding of TF-CBT’s effectiveness with unaccompanied refugees from Central America. Also, examining culturally competent strategies of implementing TF-CBT with this population is warranted.
Conclusion
The treacherous journey unaccompanied minors must undertake to arrive in the United States is not a deterring factor. Secretary Jeh Johnson from the United States DHS reported: “Border security alone cannot overcome the powerful push factors of poverty and violence that exist in Central America. Walls alone cannot prevent illegal migration” (DHS, 2016, para. 4). Even though these children and adolescents walk thousands of miles and face hostile situations on their journey to the United States, they choose this path instead of the alternative, which for many, if they stay in their home country, is certain death (United Nations Children’s Fund, 2016; Women’s Refugee Commission, 2012). Ultimately, counselors and other helping professionals must consider the instinctive nature of self-preservation, especially in children. Child and adolescent refugees will continue to come to the United States seeking food, shelter, and asylum until their home situation becomes bearable. Until then, counselors and those supporting unaccompanied minors must understand the strengths, stresses, and struggles of refugees to develop effective practices for helping these children to be successful in their receiving country.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Angelica M. Tello, NCC, is an assistant professor at the University of Houston-Clear Lake. Nancy E. Castellon is a doctoral student at the University of Texas at San Antonio. Alejandra Aguilar is a doctoral student at the University of Houston-Clear Lake. Cheryl B. Sawyer is a professor at the University of Houston-Clear Lake. Correspondence can be addressed to Angelica Tello, 2700 Bay Area Blvd, Houston, Texas, 77058-1002, tello@uhcl.edu.
Nov 25, 2017 | Volume 7 - Issue 4
Stephen P. Hebard, Katie A. Lamberson
Athletes represent a unique population with a legitimate need for counseling services; yet, counselors have done little to define and promote sport counseling. This paper represents a call to counselors, educators, and researchers to advocate for a rigorous sport counseling specialization and clarified professional identity. Counselors need to identify required competencies, teaching guidelines, and ethical codes to provide optimal mental health services to athletes and effectively co-exist among other professionals in sport. The current state of mental health services for athletes, the potential for counselors to provide unique contributions to mental health in sport, and actionable steps regarding advocacy and research are discussed.
Keywords: sport counseling, professional identity, advocacy, athletes, mental health
Athletes represent a considerable segment of the American population. As of 2016, 40% of youth aged 6 to 12 participated in team sports, a 3% increase from 2015 (Rosenwald, 2016). Recent surveys show that 8 million high school students play sports (National Federation of State High School Associations, 2015), about 525,000 participate at the collegiate level (National Collegiate Athletic Association [NCAA], 2017a), and more than 11,800 are considered elite, professional athletes (Bureau of Labor Statistics, 2014). Over the past several years, researchers have recognized that athlete mental health concerns often go largely unaddressed (Ferrante & Etzel, 2009; Nattiv, Puffer, & Green, 1997).
Athletes at every level are often perceived to be privileged and idolized for their physical prowess; however, this perception leaves them especially vulnerable to be missed when it comes to mental health concerns. In fact, as a population, athletes are described as “at-risk” of experiencing a multitude of mental health concerns. Researchers have demonstrated that athletes are susceptible to alcohol abuse (B. E. Miller, Miller, Verhegge, Linville, & Pumariega, 2002), lower levels of wellness than non-athletes (Watson & Kissinger, 2007), risky behaviors (Nattiv et al., 1997), depression (Nixdorf, Frank, Hautzinger, & Beckmann, 2013; Storch, Storch, Killiany, & Roberti, 2005; Yang et al., 2007), social anxiety (Storch et al., 2005), eating disorders (Currie & Morse, 2005), and aggression (Benedict & Yaeger, 1998), among other mental health issues. Many of these mental health concerns may result from the demands and pressures experienced by athletes. For example, some athletes have been found to over-train, which may result in depression, decreased self-esteem, or emotional instability (Raglin & Wilson, 2000). Furthermore, athletes are less likely to seek professional help than their non-athlete counterparts for mental health concerns (López & Levy, 2013; Watson, 2005). Given the growth of sport from youth to adulthood and the challenges to mental health inherent in sport participation, mental health professionals can provide support to athletes that is currently lacking. However, in order to deliver optimal care, mental health professionals must commit themselves to fully understanding the athlete experience.
Counselors are in a position to provide unique, culturally responsive mental health services to athletes; however, the profession’s presence in sport is limited due to a poorly defined professional identity and a lack of understanding of the unique skill set counselors possess. A lack of empirically derived competencies, teaching guidelines, and ethical considerations must be addressed if sport counselors hope to have a greater presence in sport. Additionally, competition with sport psychologists, who primarily address athletic performance optimization and are currently far more integrated into athlete culture, may be a barrier for counselors. However, because sport psychologists primarily educate athletes on mental skills for performance optimization and counselors directly address mental health concerns, there is room for these professionals to work together to address the overall wellness and performance needs of athletes.
The purpose of this paper is to discuss the current state of mental health services provided to athletes and to identify and address the potential barriers for counselors who wish to work in sport. In addition, the authors will provide a brief history of a vision for an integrated sport counseling specialty, gaps in counselor competence and identity necessary to establish sport counseling among widely recognized professions in sport, and suggestions for researchers, practitioners, and advocates to ensure a future for the sport counseling specialty.
The Evolution of Mental Health Services in Sport
The unique challenges of athletes were first identified in the early 1970s by a group of college counselors that would later form the National Association for Academic Advisors of Athletics (N4A; National Association of Academic and Student-Athlete Development Professionals, 2017). Their commitment to encouraging student athlete academic achievement led to an expansion of their initiative beyond academics and a moniker representative of their current mission (the National Association of Academic and Student-Athlete Development Professionals). N4A’s impact is experienced by over 40,000 athletes annually, as the organization was integral in the development of the NCAA’s CHAMPS/Life Skills (now NCAA Life Skills) program. N4A and the NCAA Life Skills program define their commitment as one that impacts athlete academic achievement, athletic performance, and personal well-being. Although there is little doubt that these programs positively impact athletes, their focus is not specific to mental health. In fact, until the early 2010s, sport organizations had done little advocacy for athletes experiencing mental health challenges. In 2013, the National Athletic Training Association (NATA) made a call for mental health practitioners to help increase mental health awareness within athletics organizations (Neal et al., 2013). NATA published recommendations for athletic trainers, who are considered the “first responders” to both physical and mental health (Burnsed, 2013a), to develop a collaborative plan to recognize and refer student athletes experiencing psychological concerns to the appropriate mental health professionals. In doing so, NATA catalyzed a long overdue shift in the philosophy and attention of stakeholders invested in the overall well-being of athletes. Soon thereafter, the NCAA (2014) recruited a Mental Health Task Force to demonstrate substantial commitment to the prioritization of mental health concerns experienced by student athletes. This task force is committed to working with coaches, medical providers, and student athletes to address the stigma commonly associated with mental health issues and how to break through barriers to mental health access (Burnsed, 2013b). Despite the positive goals the NCAA aims to achieve, counselors have yet to be represented on this task force.
Similar to these shifts at the collegiate level, professional organizations have made some strides toward recognizing the mental health needs of their athletes. For example, the National Football League (NFL)-affiliated Player Engagement Division currently provides active players with the “NFL Life Line.” The NFL Life Line is a crisis hotline for current and former NFL players that offers independent, confidential support (NFL Life Line, 2016). The actions of NATA, the NCAA, and the NFL represent a significant investment in athlete mental health that had previously been missing from the history of health considerations in sport. Recent emphasis on addressing athlete mental health issues marks a necessary and exciting opportunity for the counseling profession; yet, sport psychologists currently dominate this work, despite noted differences in focus. In order to become part of the solution to addressing the mental health needs of athletes at all levels, counselors must prioritize advocacy for athlete mental health and be able to competently describe how their involvement in sport will benefit athletes across the lifespan. A first step for counselors is to better understand the current mental health services that exist for athletes.
The majority of individualized attention to psychologically related services offered to athletes (both collegiate and professional) has historically been provided by practitioners of sport psychology. Two primary organizations exist within the sport psychology profession: the Association for Applied Sport Psychology (AASP) and American Psychological Association (APA) Division 47. AASP certifies master’s-level “consultants” who display competence in kinesiology and psychology to educate athletes on the role of psychological factors in sport performance and teach mental skills that athletes can utilize within and beyond the context of their sport (AASP, 2017). In contrast, APA refers to sport psychology as a specialization within the general practice of psychology for doctoral-level psychologists (APA, 2017). Clinical sport psychologists with proficiency through Division 47 provide clinical interventions for eating disorders, substance use, grief, depression, sexual identity issues, aggression, career transitions, and more (APA, 2017). Practical, organizational, and philosophical differences between these two primary organizations have challenged the sport counseling specialty to establish a unique identity (Aoyagi, Portenga, Poczwardowski, Cohen, & Statler, 2012). Both AASP and Division 47 identify performance optimization as a primary responsibility of sport psychologists, though licensed psychologists with the Division 47 sport psychology proficiency claim specialized knowledge in clinical and counseling issues with athletes and biobehavioral bases of sport and exercise. As a result, athletes seeking mental health services are likely to receive services from sport psychologists with disparate levels of education, varying degrees of competence, and significant differences in their goals for treatment.
This lack of potential continuity of services, coupled with the unique contributions of counseling in sport, marks an opportunity for counselors to become a major resource among athletes. Counselors can address the current discrepancy in services by approaching athlete mental health concerns from a bottom-up, rather than top-down, approach. Counselors can utilize their strength-based, wellness-oriented philosophy to prioritize mental health needs over performance in efforts to enhance performance through improving overall wellness, rather than the reverse. Specialty training in sport can create a more streamlined set of competencies and standards that fall within the general counseling guidelines, but still cater to the unique needs of athletes. Acknowledging the limitations of sport counseling’s history and its current status may encourage clarification of an identity, development of competencies and standards, and recognition of the important contributions that counseling can bring to the culture of athletics.
Sport Counseling: Past and Present
The idea of a sport counseling specialty is hardly new. In 1985, the Counselors of Tomorrow Interest Network of the Association for Counselor Education and Supervision (ACES) described a number of potential counseling specializations for exploration in their publication, Imagine: A Visionary Model for the Counselors of Tomorrow (Nejedlo, Arredondo, & Benjamin, 1985). This publication included a brief section that defined “athletic counseling” and listed associated skills (e.g., counseling, goal setting) and knowledge bases (e.g., NCAA regulations, group facilitation) necessary for practice (Nejedlo et al., 1985). Researchers and educators have since heralded the document as the foundation for defining sport counseling and the treatment of athletes. However, the purpose of this publication was not to establish fundamental principles and standards, but to outline trends, future work environments, and specialty roles in a number of different areas of counseling (Arredondo & Lewis, 2001). The authors did not intend for this list of knowledge bases and skills to serve as a rigorously developed set of competencies for counseling athletes. The intent was to provide a primer for future considerations in sport counseling. The Imagine publication does promote an apparent commitment to a wellness orientation with athletes; however, it serves as the first brick in a foundation for counselors to stand upon, not a jumping-off point for pedagogy and practice.
Hinkle (1989a, 1989b) continued to push for an established sport counseling specialty in papers presented at the Southeastern Psychological Association and Southern ACES. Hinkle also established the ACES Sports Counseling Interest Network in 1992, and the first meeting of the group was held at the American Counseling Association conference in Baltimore (J. S. Hinkle, personal communication, November 13, 2017). In two separate publications, Hinkle (1994) and Petitpas, Buntrock, Van Raalte, and Brewer (1995) made similar arguments that sport counselors must focus on the developmental and emotional aspects of the individual rather than performance optimization and mental skills training. Hinkle (1994) continued by discussing integrated treatment for athletes that included sport psychology, counseling, and developmental and educational programming, highlighting the unique contribution of each profession and the importance of taking a team approach to fully address the diverse needs of athletes. In addition, Hinkle discussed how sport counselors may work with clinical issues, career and life planning, programs for children, and a research agenda.
Though little formal evidence exists, several hurdles have impacted forward progress in the sport counseling arena. For example, there is anecdotal evidence that counselors may view athletes as a population unworthy of services. When asked why G. M. Miller and Wooten’s (1995) sport counseling proposal to the Council for Accreditation of Counseling and Related Educational Programs (CACREP) was never adopted, H. R. Wooten shared, “It appeared that working with athletes was a little ‘boutique’ for most counselors as athletes continued to be seen as privileged” (personal communication, May 27, 2014). Poor visibility among other health professionals working in sport, few opportunities for supervised internships due to a lack of licensed professionals working in sport, limited counseling research with athlete populations, and minimal commitment to athlete mental health until recent years all may have had an effect on the pace at which sport counseling has advanced. Despite counseling researchers’ and advocates’ efforts to move sport counseling forward, more than 20 years later, counselors remain committed to the descriptors of the Imagine publication, but need clarity in professional identity and service provision.
At present, counselors who desire specialized knowledge in working with athletes may be confused by the way that the specialty is being defined and marketed. For example, athletic counseling, is a term used to market academic programs that prepare students for AASP certification and employment in applied sport psychology. Graduates of these programs are not counselors; rather, they meet criteria necessary to be recognized as a Certified Consultant of the Association for Applied Sport Psychology (CC-AASP). A CC-AASP is recognized as an individual trained to enhance athletic performance through mental skills training (AASP, 2017), but it is not a credential that prepares individuals to provide counseling to athletes. A CC-AASP does not participate in many of the typical responsibilities of counselors, including the diagnosis of mental health disorders, substance abuse counseling, and marital or family counseling (AASP, 2017). Counseling certificate programs also utilize the athletic counseling moniker to market their specialized curriculum to licensed counselors, suggesting these programs see a benefit in providing additional training in athletics to individuals already trained as counselors. This model recognizes that the foundational knowledge and skills essential to licensed counselors are important regardless of population or setting. Thus, specialized training related to working in athletics in addition to the core training of licensed counselors may be the best way to maintain cohesion within the counseling profession while still providing athletes with the specialized services they need. Unfortunately, confusion among athletes, coaches, administrators, and other professionals exists because there is a lack of significant knowledge of sport and mental health, which may be the result of a lack of a clear model within the mental health professions about what sport counseling should look like and the distinctive role sports counselors can have when working with athletes. We believe that a commitment to establishing a clearer sport counseling identity would distinguish sport counseling programs like those at Springfield College, California University of Pennsylvania, and Adler University from other programs and would provide enhanced opportunities for graduates wanting to work in athletics.
Implications and Future Directions for Sport Counseling Researchers and Practitioners
Counselors must consider the question: “If the need for sport counselors exists, why haven’t they proliferated among sport organizations?” This question is not easily answered without significant inquiry; still, there is evidence that begins to tell the story. Certainly, the ubiquity of a stigma against mental health in athletics has historically inspired hesitation to seek help (Brewer, Van Raalte, Petitpas, Bachman, & Weinhold, 1998). In fact, counselors are no strangers to this stigma. Historically, individuals have hesitated to seek assistance for mental health concerns due to the societal stigma mental health carries. Over the years, education and awareness efforts have decreased mental health stigma; however, the profession of counseling has continued to struggle with identifying itself as a profession distinct from other mental health professions (Remley & Herlihy, 2016). To mitigate this struggle, counselors have worked tirelessly to educate and advocate for the professional identity of counselors. In doing so, counselors have utilized Nugent’s (1980) guidelines for identifying a mature profession to gain professional distinction (Remley & Herlihy, 2016). These guidelines include having a clearly defined role and scope of practice, offering unique services, having specialized knowledge and skills, having a code of ethics, obtaining legal rights to offer services through licensure and certification, and having an ability to monitor professional practice (Nugent, 1980). In order to achieve these criteria, some members of the profession promote viewing counseling as the predominant profession with specialty areas that continue to support the primary profession (Remley & Herlihy, 2016). As one of the potential specialties, the area of sport counseling can learn from the progress the primary profession of counseling has accomplished. Utilizing the parallels present in the journey of the counseling profession as an example, sport counseling also can develop a mature identity within the counseling profession. Despite this area’s history and obstacles to proliferation, there are many ways that counselors can play an active role in building the sport counseling specialty.
Counselors interested in working with athletes must focus on the development of a comprehensively developed identity. Sport counseling lacks dedicated documentation of the behaviors that practitioners perform. The values and beliefs that distinguish sport counseling from related professions need to be identified. At minimum, the development of competencies, teaching and practice guidelines, and ethical codes are necessary to establish an identity that is separate but compatible with existing services for athletes, while still remaining true to the overall counseling profession. As advocates of a sport counseling specialization begin to take concrete steps toward promoting professional identity, practitioners may be better able to market themselves to stakeholders and find opportunities to begin meeting the mental health needs of athletes.
The 20/20 Vision for the Future of Counseling (20/20; Kaplan & Gladding, 2011) marks an important step in the establishment of a clear and succinct philosophy representative of all counselors. The 20/20 research team used Delphi methodology, an approach to structuring and organizing experts to come to consensus on an area of incomplete knowledge (Powell, 2003), to invite leaders in counseling to determine an updated, more appropriate definition to clarify the profession’s identity (Kaplan & Gladding, 2011). In an effort to unify as one counseling profession, counselors advocating for a distinct sport counseling specialty must consider 20/20 as an opportunity to enhance its professional identity. The development of a disparate or duplicated area would result in further fragmentation. Ultimately, the authors believe that a sport counseling specialty would be best defined by starting with our already existing 20/20 philosophy: “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan, Tarvydas, & Gladding, 2014, p. 366). Further, 20/20 may serve as an important launching pad from which sport counseling advocates can begin to stake out their domain.
A first step in the establishment of the sport counseling specialty is the rigorous development of competencies that are germane to the practice of working with athletes. Competencies, knowledge, skills, and attributes that represent professional qualifications necessary for effective practice may help sport counselors understand and communicate their identity. A lack of an empirically derived set of sport counseling competencies limits sport counselors’ ability to establish their identity and expertise. Researchers should consider the use of Delphi methodology to determine knowledge, skills, and attributes necessary to treat athlete mental health needs at the highest level. Delphi has been performed effectively to outline guidelines for competence in other areas of counselor education (Wester & Borders, 2014), providing evidence for its potential effectiveness in establishing sport counseling competencies. Future considerations for sport counseling competencies may include understanding the demands of the athletic experience, privacy concerns associated with athletic settings, the role of physiology in sport, the influence of competitive environments on mental health, sport culture, the importance of building relationships with athletes and associated individuals (e.g., coaches, athletic trainers, administrators), and additional athlete-specific issues. Researchers might consider querying counselors in practice with athletes, instructors teaching sport counseling courses in counselor education programs, clinical and applied sport psychologists, athletes, and other relevant parties in sport to establish specific areas of competence necessary for sport counselors.
Leaders in sport counseling must also revisit and revise G. M. Miller and Wooten’s (1995) proposed teaching guidelines published in the Journal of Counseling & Development in 1995. G. M. Miller and Wooten cited Nejedlo et al.’s (1985) aforementioned publication and the Association for the Advancement of Applied Sport Psychology (now AASP) as foundational influences on curriculum development. The curriculum was meant to be integrated with the common core and clinical experiences required by CACREP to provide training standards necessary for practice in sport counseling. The 1995 teaching guidelines were ultimately published, but a plan for their adoption was never established. G. M. Miller and Wooten’s publication serves as an important step toward the integration of sport counseling and counselor education that needs to be addressed more fully. A foundation of researched and well-reasoned competencies will eventually give way to curricular guidelines to anchor and clarify sport counseling identity, practice, and ethics.
The adoption of a new code of ethics may not be necessary; however, there are special circumstances for counselors to consider when working with athletes and sports organizations. For example, ethical standards related to confidentiality and relationships with other professionals can apply to working with athletes, coaches, and other athletic staff; however, more explicit statements related to exceptions to confidentiality and how to work effectively on behalf of the athlete while still respecting a referral from a coach may be helpful for counselors working in athletic settings. Sport counselors may find it prudent to learn from sport psychologists, who typically navigate similar work environments. According to sport psychologists Etzel and Watson (2007), several ethical challenges exist that may present themselves on a daily basis.
One primary ethical challenge that sport counselors may face is determining who their client is when working with individual athletes on a professional or university team. Athletic departments responsible for paying for mental health services, as well as coaches and support staff, may assume that they should be made aware of an athlete’s mental health status. Etzel and Watson (2007) pointed out that athletes are perceived by their managers as controlled investments; there is an expectation of being informed and in control. Ethical guidelines must be made clear for sport counselors to negotiate such challenging situations. Additional challenges include navigating multiple roles (e.g., counselor, team consultant, advisor to coaches), impromptu consultations that occur outside of the counseling session, NCAA and professional rules and regulations, and the likely possibility that other parties will notice an athlete seeking the professional’s services if housed in a university or team setting, among countless other potential dual relationships. The establishment of competencies, training guidelines, and ethical standards that apply specifically to counselor–athlete and counselor–team relationships may appear to be a daunting task. Counselors and counselor educators interested in sport must collaborate and advocate for a strongly anchored position in athletics by committing to the development of these foundational elements of sport counseling practice.
Counselors must acknowledge existing and potential outlets for collaboration if sport counseling is to evolve. The ACES Sports Counseling Interest Network, started by Hinkle in 1992, provides a space for counselors interested in discussing present challenges and supports to the growth of sport counseling. Utilization of this medium for collaboration on future research and presentations is vital to the health and expansion of this specialty. Counselors must consider the importance of offering psychoeducational workshops, connecting athletes to mentorship, and developing other organizational supports for athletes in need. These efforts will help to rightly justify counselors’ push for professional inclusion in sporting contexts. An early step will be to normalize the existence of sport counselors among other professionals advocating for improvements to athlete mental health. Counselor membership on the NCAA Mental Health Task Force is a necessary step to becoming a more widely known and respected entity. As sport counselors become more mainstream and accepted professionals in sport, licensed counselors could provide opportunities to counselors-in-training who require supervised internships before starting their careers as sport counselors. Without active networks for collaboration, counselors remain isolated and perhaps less likely to catalyze change.
Developing these professional relationships is critical to gaining entry and contributing to change in sport. Collaborations with organizations committed to athlete health could encourage other like-minded organizations to consider the expertise of counselors. For example, the Institute to Promote Athlete Health and Wellness (IPAHW) at the University of North Carolina at Greensboro, in collaboration with Prevention Strategies, LLC, is an organization committed to the improvement of athlete health and wellness through behavioral intervention programs, policy making, evidence-based training, and intervention evaluation. IPAHW has collaborated with the NCAA Sport Science Institute to ensure that student athletes have access to “myPlaybook: The Freshman Experience,” a catalog of web-based trainings that facilitate behavior change in student athletes across topics like: social norms related to alcohol and drug use, bystander intervention, mental health, time management, hazing, sleep wellness, and sport nutrition (IPAHW, 2017; J. J. Milroy, personal communication, October 3, 2017). Additionally, IPAHW and the NCAA Sport Science Institute are rolling out a new sexual violence prevention course in response to the NCAA’s new policy that requires coaches, student athletes, and administrators to receive sexual violence prevention education (NCAA, 2017a). Counselors have significant training and expertise that may enhance the work of these organizations advocating for health promotion among athlete populations.
Sport counselors must aim to publish athlete mental health research and seek grant funding for experimental research to further establish this specialty. Though relatively new itself, sport psychology has established several journals that address both performance-oriented (e.g., Journal of Applied Sport Psychology) and clinical (e.g., Journal of Clinical Sport Psychology) issues in sport that have yet to be fully explored by counseling researchers. A solidly established sport counselor identity may lead to the eventuality of a sport counseling journal; however, there is a current lack of leadership committed to this task. As the foundational elements detailed above are established to move sport counseling forward, a journal will become a necessity for researchers to expand their knowledge of athlete mental health needs and counselor interventions. Sport counseling researchers publishing in counseling and related journals may need to consider opportunities to fund experimental pilots and larger scale projects. Opportunities for grant funding in sport, although few, are available and range in size and scope. The National Institutes of Health has committed significant funding to the diagnosis of chronic traumatic encephalopathy, a progressive, degenerative brain disease diagnosed at a high rate among deceased athletes of the NFL (Diagnose CTE, 2017). The Center for Healthy African American Men through Partnerships (2017) has expressed interest in funding research on head trauma in athletes. The NCAA annually supports researchers with pilot funding for alcohol abuse intervention and innovative projects designed to enhance student athlete well-being (NCAA, 2017b). Counseling researchers have not procured funding through these opportunities.
Conclusion
More than ever, Myers, Sweeney, and White’s (2002) assertions that counselors must establish their professional identity, enhance their public image, and develop strong interprofessional, collaborative networks remain both relevant and necessary. Counselors currently attempting to break into the safeguarded culture of athletics may struggle to establish credibility and communicate a unified identity. Currently, counselors in sport have a small foundation to stand upon when discussing the specialization of their services to athletes and athletic staffs. The gaps to be filled are clearly labeled and ready to be addressed. The future of sport counseling requires bolstering the literature that outlines its professional development. Counselors involved in sport need to develop relevant research initiatives, obtain funding, and pilot experimental studies that show evidence of improved mental health outcomes with athletes. The marketability of a sport counselor relies on the ability to demonstrate effectiveness with athletes and collaborate with the professional fields that currently saturate sporting contexts. The prospect of a thriving sport counseling specialty is within the counseling profession’s reach. Counselors must now cultivate a sport counseling identity that clearly projects their viability, marketability, and potential for positively influencing athlete mental health.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Stephen P. Hebard, NCC, is an assistant professor at the University of Alabama at Birmingham. Katie A. Lamberson is an assistant professor at the University of North Georgia. Correspondence concerning this article should be addressed to Stephen Hebard, Department of Human Studies, The University of Alabama at Birmingham, 1720 2nd Ave S., EB 207, Birmingham, AL 35294-1250, sphebard@uab.edu.
Oct 17, 2017 | Book Reviews
Dr. Gerard Vernot addresses student behavior as an encompassing issue that many are finding difficult to manage and provides strong solutions that are applicable to all. Helping Students Eliminate Inappropriate School Behavior does not seek to blame but instead inspires readers to push forward by providing realistic activities that are appealing to middle and high school students. This book incorporates many learning styles and needs with consideration of children’s developmental processes. With consideration given to different cultures, the material presented in this book encourages readers to understand their students beyond their behavior in the classroom. This approach shifts the focus of inappropriate behavior from the individual student to a systemic perspective. Dr. Vernot advocates for educators and counselors to recognize the needs of our students and to respond effectively to their needs by engaging and increasing students’ awareness.
Dr. Vernot provides adaptable, evidence-based activities that create foundational structure. The activities included by Dr. Vernot are derived from the literature provide a foundational structure. Each activity provides detailed instructions that set up the structure of the activity, what is needed to make the activity successful, and how the facilitator can process after the activity. Clear directions and examples allow educators and counselors to efficiently and effectively decide the most appropriate activity for a student(s), meeting the demands of facilitators who use this resource on a daily basis. The activities included address a variety of behavioral concerns while helping students gain skills in areas of communication, cooperation, conflict management, and problem-solving techniques. These are crucial tools that we all aim for students to learn while in the academic setting, and these activities can provide additional support to teacher and counselors when structuring each class.
Although Dr. Vernot makes significant contributions by compiling a guidebook to address problematic behaviors, these activities alone will not change the behaviors. Crucial factors, such as familial support, environment, developmental level of the student, and systemic structures of the student’s school and culture, should be considered in addition to the intentional activities provided in the book. These considerations can holistically create the space for students to recognize their behaviors and empower change. Implementation of activities to address behaviors may not have a long-term success without initially understanding the development of the behavior.
The content addressed in this book can appeal to a variety of counseling professionals. Although the specific roles of school counselors, counselor educators, and Licensed Professional Counselors differ, each can find value in implementing the activities provided in their work with children and adolescents. These tools can be used to build foundational trust and rapport that is needed throughout the counseling profession. In addition, the activities suggested in this book can be seen as normal engagement by children and open the space for appropriate interaction with their peers, teachers, or counselors.
Vernot, G. (2016). Helping Students Eliminate Inappropriate School Behavior: A Group Activities’ Guide for Teachers and Counselors. Bloomington, IN: AuthorHouse.
Reviewed by: Jillian M. Blueford, NCC, The University of Tennessee, Knoxville
The Professional Counselor
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Oct 10, 2017 | Volume 7 - Issue 3
Yanhong Liu, Dan Li, Yanqing Xu
Indiscriminate friendliness (IF) is a prominent issue with children adopted from China to the United States. Through a mixed methods design, the authors explored four Chinese adoptees’ experiences of IF within their real-life context, investigated potential factors associated with IF, and examined the IF–attachment relationship. This mixed methods study consisted of a qualitative case study of four children adopted from China and a quantitative investigation into IF using a sample of 92 adoptive parents with Chinese adoptees. The qualitative findings revealed crucial propositions related to children’s IF, and the quantitative results provided further evidence to corroborate the qualitative findings. This study reinforced the stance that IF should be treated as a distinct construct from attachment. Researchers and professional counselors can benefit from the results of this study to better serve Chinese adoptive families.
Keywords: indiscriminate friendliness, children, China, adoptive families, mixed methods
According to intercountry adoption statistics, the United States welcomed 261,728 children across the world from 1999 to 2015 (U.S. Department of State, Bureau of Consular Affairs, 2016). Among these adopted children, 76,026 (approximately 30%) came from China, which made China the largest country of origin for intercountry adoption. A majority of Chinese adoptees were under 3 years old at the time of adoption (U.S. Department of State, 2016). Numerous issues have been detected related to the intercountry adoption process (Kreider & Cohen, 2009; van den Dries, Juffer, van IJzendoorn, & Bakermans-Kranenburg, 2009). A prominent issue is children’s indiscriminate friendliness (IF; Bruce, Tarullo, & Gunnar, 2009; Chisholm, Carter, Ames, & Morison, 1995; van den Dries, Juffer, van IJzendoorn, Bakermans-Kranenburg, & Alink, 2012). IF refers to children’s excessively friendly behaviors toward adults (other than their primary caregivers) without appropriate screening of the adults (Tizard, 1977). IF has been consistently identified in post-institutionalized children (Bruce et al., 2009; Chisholm et al., 1995) and has been viewed as pathological in nature (American Psychiatric Association [APA], 1994, 2013).
Previous research studies have yielded different post-adoption adjustment outcomes in Chinese adoptees compared to domestic adoptees or other internationally adopted children, including optimal behavioral adjustment (Cohen, Lojkasek, Zadeh, Pugliese, & Kiefer, 2008), successful attachment formation (Liu & Hazler, 2015), and positive academic performance (Tan & Marfo, 2006). The distinction between Chinese adoptees and their research counterparts entails a closer look at this population. Investigation into IF in children adopted from China became important, as the majority of them had experienced pre-adoption institutionalization in China. Consistent with earlier findings about post-institutionalized children (Bruce et al., 2009), IF has been identified as a significant issue in children adopted from China and was supported by the only study targeting Chinese adoptees in the United States (van den Dries et al., 2012).
A dearth of knowledge on IF in Chinese adoptees in the United States necessitated an in-depth qualitative investigation into this phenomenon in the adoptees’ real-life context (Yin, 2014). However, a single qualitative study cannot offer a comprehensive view of IF, nor can it thoroughly address all research questions for this study; thus, by adding a quantitative investigation, this study sought to compensate for the inadequacy of the qualitative methodology and allow researchers to triangulate and compare dissonant data between the two research approaches (Plano-Clark, Huddleston-Casas, Churchill, Green, & Garrett, 2008).
Indiscriminate Friendliness (IF)
IF, alternatively termed indiscriminately friendly behavior or indiscriminate overfriendliness, refers to a behavioral tendency for children to seek attention and approval from adults, including strangers (Hodges & Tizard, 1989; Tizard & Hodges, 1978). IF is also referred to as disinhibited attachment behavior or disinhibited social behavior, evidencing post-institutionalized children’s overfriendly behavior toward unfamiliar adult figures (Bruce et al., 2009). IF does not fall into the traditional sense of being friendly, which is associated with a positive human trait; instead, it is deemed behaviorally inappropriate when children actively approach strangers, without a reasonable assessment of whether or not it is safe to do so (Bruce et al., 2009; O’Connor et al., 2003).
Researchers have noted that children’s institutionalization experiences play a significant role in IF development, albeit adopted children are able to form strong attachments with their adoptive parents given adequate time (Chisholm, 1998; Hodges & Tizard, 1989; Tizard & Hodges, 1978). Post-institutionalized children with IF tend to approach, make personal comments to, and initiate physical contact with strangers, and children with a high level of IF are often willing to leave locations with strangers (Bruce et al., 2009). They also allow unfamiliar adults to put them to bed and comfort them when they are hurt (Tizard & Hodges, 1978). A multitude of adoptive parents have had concerns about their children’s safety as a result of their IF behaviors (Bruce et al., 2009).
In Tizard and Hodges’ (1978) follow-up study in the United Kingdom, one third of formerly institutionalized children exhibited excessive attention-seeking behaviors and a tendency to be overfriendly to adults. A few children, from ages 4 to 8, presented indiscriminate affection toward adults. In Bruce et al.’s (2009) sample of internationally adopted children in the United States following institutionalization, 65% displayed IF characteristics. Likewise, in Chisholm’s study (1998), Romanian adoptees in Canada exhibited significantly more IF behaviors than the two comparison groups: (a) Canadian-born, non-adopted, and non-institutionalized children; and (b) early-adopted Romanian children who were adopted before the age of 4 months. In contrast to institutionalization’s role as a risk factor of IF, adoptive parents’ responsive parenting was assumed to be a protective factor for children’s post-adoption behavioral adjustment (van den Dries et al., 2012). Responsive parenting entails a high level of warmth and nurturance in the process of caretaking, including offering timely attendance to children’s needs (Darling & Steinberg, 1993).
Attachment
Theorists have examined the relationship between IF and attachment (Bowlby, 1982; Sabbagh, 1995). For example, Bowlby (1982), defining attachment as a child’s behavior to seek physical proximity to his/her primary caregiver, claimed attachment as a correlate to IF. Attachment, viewed as a social behavior, occurred as a result of certain behavioral systems activated when infants interact with the “environment of evolutionary adaptedness” and the mother figure in the environment (Bowlby, 1969, p. 179). The first two to three years are the most critical period for children to develop relationships with caregivers and to develop the aforementioned behavioral systems (Bowlby, 1969). Given an environment in which evolutionary adaptedness is absent, such as an institutional rearing environment, atypical discriminating attachments may ensue (O’Connor et al., 2003). Although many securely attached children displayed IF behaviors, their unattached counterparts demonstrated a higher likelihood of being overfriendly (Bowlby, 1982).
Evolution of Diagnostic Criteria
In addition to the heated dispute on whether or not IF is related to attachment patterns, the clinical perspective on IF has been evolving. In the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994), IF was termed the disinhibited type (i.e., indiscriminate sociability), as opposed to inhibited type (i.e., social withdrawal), under the Reactive Attachment Disorder diagnostic criteria. Similarly, the International Statistical Classification of Diseases and Related Health Problems (10th rev.; ICD-10; World Health Organization [WHO], 1992) named IF as a disinhibited attachment disorder. Both the DSM-IV and ICD-10 described IF as an abnormal pattern of relatedness that begins before the age of 5 years (APA, 1994; WHO, 1993). Nevertheless, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) redefined IF as a disinhibited social engagement disorder, which is a trauma- and stressor-related disorder derived from severe neglect in the first two years of life. Hence, IF was separated from reactive attachment disorder, where it had been categorized.
The mixed findings on potential contributors to IF and the lack of in-depth qualitative input on IF reinforce the need to address IF in children adopted from China, which has rarely been discussed in counseling journals. Prevalence of IF in Chinese adoptees in the United States remains unknown, and no study was found exploring the experiences of children with IF. The purpose of this study was to better understand IF in children adopted from China by U.S. families. The authors conducted a case study on four Chinese adoptees through two in-depth semi-structured interviews with two U.S. adoptive mothers. To ensure the robustness of this study, the authors conducted a follow-up quantitative investigation into IF using a sample of 92 adoptive parents with children adopted from China. This study addressed three research questions—RQ1: How do parents perceive IF in children adopted from China?; RQ2: What are some potential factors that are associated with IF?; and RQ3: Is IF related to children’s attachment? The overarching goal of the current study was to provide an in-depth understanding of Chinese adoptees’ IF in its real-life context, to probe into the potential predictors of IF, and to examine the relationship between IF and attachment.
Method
Participants
Participants for qualitative and quantitative investigations were drawn from U.S. adoptive parents with children adopted from China. Participants for the qualitative case study did not participate in the quantitative stage of investigation. The recruitment of participants represented a parallel relationship between qualitative and quantitative samples (Leech & Onwuegbuzie, 2010), ensuring the comparability of the two data sources. The same datasets have been investigated with different emphases, by one earlier submitted manuscript investigating child-parent attachment (Liu, 2017). The quantitative dataset was also used by another study that followed a hierarchical regression analysis on IF associative factors (Liu & Hazler, in press). Research questions for this study were distinctly independent from previous studies. Participants were recruited based on the following criteria: (a) participants were U.S. citizens who adopted children from China; (b) children adopted by participants were 3 years old or younger at the time of arrival (U.S. Department of State, 2016); and (c) children were younger than 6 years old at the time of data collection (APA, 1994, 2013; WHO, 1992).
Two White mothers, Amy and Tina, were recruited for a qualitative case study from the first author’s network from her previous work with adoptive families. Amy and Tina each adopted two children from China. The case study focused on the four children’s IF behaviors and related experiences. Parents, instead of the children, were selected as the participants, as all of the four children were under 6 years old and had limited ability in comprehending and articulating the phenomenon. Both participants were married and had tried to have biological children. Natural conception was not a possibility, so adoption became the alternative to fulfill the desire for parenthood. Amy was in her late 40s at the time of the interview. Amy had been a stay-at-home mother for her children, Amelia and Beatrice. Tina was around 50 years old at the time of the interview. Tina worked full-time at a research organization, while her husband had been the primary caregiver of their two children, Rebecca and Joshua. The ages of the four children at the time of arrival in the United States were: Amelia, 10 months; Beatrice, 3 years; Rebecca, 11 months; and Joshua, 2 years and 10 months.
Participants for the quantitative investigation consisted of 92 White parents who adopted children from China. Participants ranged from 31 to 59 years old (M = 46; SD = 6.4). Eighty-six (94%) of the participants were adoptive mothers of the children, and six (6%) were adoptive fathers. Sixty-two participants (67%) had two or more Chinese adoptees. A majority of participants (86%) held a bachelor’s degree or higher. More than half (70%) of the participants identified themselves as primary caregivers of the children, and the rest reported as equal caregivers (i.e., the participants and their spouses take an equivalent amount of caregiving responsibilities). Over half of the participants (53%) worked 20 hours or below per week or held no employment, and 47% of the respondents worked more than 20 hours per week. The average age of the children at the time of arrival in the United States was 19 months.
Sampling and Recruitment
Two separate Institutional Review Board approvals, for the qualitative case study and the quantitative investigation, were obtained from the first author’s institution where the study was conducted. The authors used the purposeful sampling method (Teddlie & Yu, 2007) to recruit the case study participants following the aforementioned screening criteria. The first author’s previous encounters with Chinese adoptees and adoptive families evoked her research interests in this population. The first author was transparent about her role as a researcher, distinct from her other roles (i.e., as a previous counselor for the children), when communicating with the participants. Amy and Tina each endorsed an informed consent form prior to their participation in the study. The form detailed the purposes and significance of this study, risk of participation, and confidentiality.
The 92 participants for the quantitative investigation were randomly recruited through adoption networks and professional organizations. The authors contacted all Children from China local chapters across all U.S. states, consisting of families with children adopted from China, and several online adoptive parent organizations. The study was endorsed by several Children from China chapters and one Chinese adoption agency. The study was also shared by administrators of several online organizations, including Chinese Adoptive Families, China Report, and Chinese Adoption. Parents who were interested in participating in the study e-mailed the first author; the first author then checked the eligibility of interested parents and provided a letter detailing the purpose, significance, risks, and confidentiality related to participation into this study. Participants were directed to the selected surveys (under the Instrumentation section) posted on PsychData. Participants of the study represented a wide geographic coverage.
Instrumentation
A semi-structured interview was conducted with Amy and Tina, separately, to understand their children’s IF and to gain a totally fresh perspective toward IF, bracketing researchers’ worldviews (Creswell, 2013). Both interviews were performed by the first author, via phone with Amy, and in person with Tina. Each interview lasted for about one and a half hours. The interviewer asked open-ended interview questions to encourage participants to expand on answers related to IF (Creswell, 2013). The interview included five open-ended questions and allowed participants to expand on any area in which they felt it useful to communicate their understanding and children’s experiences of IF. For example, the interviewer asked: How has IF been demonstrated in your children?; What have you noted in terms of your children’s friendly behaviors?; and what has influenced your children’s behaviors based on your perceptions?
Quantitative data were generated from a self-report questionnaire posted on PsychData, consisting of measures for attachment and IF along with items measuring children’s former institutionalization experiences and parents’ caregiving quality. Attachment was measured by the adapted Attachment Q-Sort (AQS; Chisholm et al., 1995), which was based on the original AQS developed by Waters and Deane (1985). The adapted AQS contained 23 items measured by a 5-point scale, from 1 = very unlike my child to 5 = very like my child. A sample item from the adapted AQS was: “Your child clearly shows a pattern of using you as a base from which to explore, that is, he/she moves out to play, returns, and then moves out to play again.” Scores for the 23 items were summed, leading to a total attachment score. A higher attachment score means that a child was better attached with the respondent. Van IJzendoorn, Vereijken, Bakermans-Kranenburg, & Riksen-Walraven (2004) reported a modest stability of AQS for the first five years of children’s lives. In the Netherlands, Pool, Bijleveld, and Tavecchio (2000) applied the instrument to assess attachment security in 45 children with ages ranging from 2 to 6 years old. Good convergent validity of AQS has been established, with a .50 correlation (r score) between AQS and the Strange Situation Procedure (Vaughn & Waters, 1990). Reliability of the adapted AQS was manifested through Cronbach α coefficients, ranging from .65–.72 (Chisholm et al., 1995) to .77–.80 (Chisholm, 1998). The Cronbach α value for this study was .83.
IF in this study was measured by the frequently used Five-Item Indiscriminately Friendliness Measure (i.e., the 5-item IF measure; Chisholm et al., 1995). The five items represent uncommonly friendly behaviors exhibited by children. The five items measure children’s friendliness level to strangers; whether or not the children were shy/behaved in a strange manner; children’s reactions to newly met adults; children’s willingness to go home with newly met adults; and children’s tendency to wander. Respondents selected 1 = Yes if the child showed the described behavior in the item; if no untypical friendly behavior was detected in the child, a 0 = No was chosen. A higher IF score indicates that the child displayed a higher level of IF behaviors. The Cronbach α coefficients of the measure were .58–.72 in Chisholm (1998) and .78–.81 in Pears, Bruce, Fisher, and Kim (2011). The Cronbach α value of the measure in this study was .58. The internal consistency was relatively low but acceptable based on similar values generated in earlier studies by the same measure (Chisholm, 1998; van den Dries et al., 2012).
In addition to the two existing measures, a demographic survey was included in the quantitative questionnaire, including questions asking children’s ages and institutionalization experiences. Children’s institutionalization experiences were assessed using questions on children’s physical growth statuses when arriving in the United States (i.e., weight), their length of institutionalization, and participants’ perception of the institutional care that their children had received prior to adoption (i.e., 1 = was not in an orphanage; 2 = high quality care; 3 = acceptable quality care; 4 = poor quality care). A higher total institutionalization score implied more positive institutionalization that a child had experienced. Parents’ caregiving quality/responsive parenting was measured by the authoritative parenting subscale of the Parenting Styles and Dimensions Questionnaire (Robinson, Mandleco, Olsen, & Hart, 2001), with a Cronbach α value of .84 for the present study.
Research Design
The current literature on IF indicates the complexity of the phenomenon because of its frequent occurrence in post-institutionalized children and its intertwined relationships with children’s nurturing environments (APA, 1994, 2013). A mixed methods study provides a better understanding of a complex phenomenon than either a single qualitative or quantitative study (Creswell, 2013). Specifically, this study utilized a sequential mixed methods design to explore Chinese adoptees’ IF within their real-life context. It comprised a two-part process, with an initial case study exploring four Chinese adoptees’ experiences of IF and a further quantitative investigation following the propositions generated from the case study. The authors consider a qualitative case study appropriate because a case study is a robust empirical approach investigating a case unit in its real-world context (Yin, 2014). The case unit includes, but is not limited to, an individual, a group, a family, a geographic region, or a particular phenomenon that is worthy of thorough investigation. It is considered an ideal methodology when “how” or “why” research questions are asked (Yin, 2014). The case unit for this study is the four Chinese adoptees’ experiences of IF. Yin (2014) defined a proposition as an essential component within a case study, guiding data collection and analysis to avoid superfluous information. Propositions are generated through literature review and/or experiences of the researchers and/or participants (Yin, 2014). The propositions from the qualitative case study guided the quantitative investigation. Both types of findings were triangulated and integrated in the Results section (Plano-Clark et al., 2008).
Procedures
Trustworthiness. Researcher reflexivity, peer debriefing, and data triangulation ensured the trustworthiness of the qualitative case study (Hunt, 2011). The authors attained researcher reflexivity through examining and suspending personal beliefs (Hunt, 2011). Qualitative data in this study were triangulated through quantitative data (Leech & Onwuegbuzie, 2010). One procedure to ensure the trustworthiness of case study methodology is to incorporate data from multiple sources (Yin, 2014). Data from the two semi-structured interviews served as the primary data source, and memo writing by the first author offered a supplemental data source. Memo writing was a documentation of the researcher’s reflections or reactions while reviewing the raw interview transcripts (Creswell, 2013). The qualitative data were transcribed by the first author and were independently analyzed by the first, second, and third authors. All three authors then thoroughly reviewed each other’s coding and reached a consensus on data categorization. An expert in adoption research served as the external reviewer of the qualitative results to ensure that data interpretations were reasonable.
Data Analysis. The authors followed the recommended data analysis strategy of pattern matching (Yin, 2014). Synthesizing the current literature and information pertaining to participants’ experiences, the research team generated five propositions: (a) children immediately bonded with adoptive parents soon after adoption; (b) children initiated IF behaviors to newly met adults; (c) children responded to affectionate behaviors by newly met adults; (d) age, institutionalization, and adoptive parents’ love/responsive parenting were potentially associated with children’s IF behaviors; and (e) there was no clear conclusion on whether children’s IF was related to their attachment to parents, which warranted a further examination of the IF–attachment relationship.
Each of the authors used the propositions to organize raw data, perform coding and data reduction, and categorize meaningful units (Creswell, 2013). The authors carefully examined all meaning units and performed pattern matching to link the meaningful data units with the propositions (Yin, 2014). Full descriptions were provided on each of the propositions with supportive data from the two in-depth interviews. The researchers analyzed the quantitative data using SPSS Statistics 20. Researchers conducted univariate, bivariate, and multiple regression analyses on the quantitative dataset, examining potential factors associated with IF, as well as the IF–attachment relationship.
Results
Results of this study included both qualitative and quantitative findings in response to the five propositions; both types of findings were triangulated, compared, and integrated into this section. Both datasets shed light on the three research questions. Each proposition was discussed and supported by qualitative data. Quantitative evidence was integrated into this section as a way to corroborate qualitative findings. Consistencies and discrepancies were identified between the two sets of data.
Research Question 1: How do parents perceive IF in children adopted from China?
Participants Amy and Tina reported IF as a prominent issue in all four of the children. The first three propositions were highlighted in the answer to Question 1. Quantitative results were consistent with qualitative findings, both of which are discussed in depth in the following paragraphs.
Children immediately bonded with adoptive parents soon after adoption. Adoptive parents were not considered as a child’s primary caregivers back to the time of adoption because of the brief time they had spent with the child. Adoptive parents, under that circumstance, were categorized as newly met adults. Amy shared that Amelia bonded immediately with her, followed by a successful adjustment. Amy further described that, in the very first night after they adopted Amelia, “she was laughing with us, smiling, giggling, and hugging us.” Tina shared similar patterns from Rebecca, who immediately bonded with her and her husband and presented as happy despite the fresh separation from her orphanage caregivers.
Children initiated IF behaviors to newly met adults. Initiating affectionate behaviors to newly met adults was a significant indicator of IF (Tizard & Hodges, 1978). Amy and Tina shared this pattern as a common concern, with the fear that children were likely to be taken away by strangers. Participants characterized children’s behavior or tendency to show friendliness to strangers as boundary issues. These boundary issues were manifested vividly in Joshua. Tina reflected that Joshua would wander off and approach anybody, even though he was aware of the family’s presence. Tina provided several concrete examples to explain Joshua’s IF behaviors, including his actively seeking proximity specifically to women whom he first met. Tina recalled that Joshua approached a newly met woman at an airport. He also walked up to another woman at the beach, sat down next to the woman, and demonstrated a high level of physical affection toward her (e.g., running his hands through the woman’s hair). Tina added that Joshua was never hesitant to ask for food from strangers and often managed to get snacks from people from his stroller when they were in China.
Children responded to affectionate behaviors by newly met adults. Children’s friendly behaviors also were manifested through their reactions to strangers’ affectionate behaviors. Both participants indicated that although parents were sensitive to children’s initiation of friendly behaviors, children’s reactions to strangers were not given equal attention. It could be a risk factor depending on who the stranger is and the underlying drive that the stranger had in approaching a child. Participants noted that children would accept food from unknown adults. Tina responded that it was common to witness Joshua walking to strangers and returning with food or snacks. Affectionate reactions to strangers happened frequently among the four children at different places. Tina recalled that at a local grocery store, a cashier picked up Joshua and showed him her computer screen, and Joshua responded with excitement and joy, without any sense of reservation. The participants indicated that even though children’s friendly reactions to strangers may not necessarily mean that they were indiscriminately friendly to all adult figures, the unreserved friendliness revealed a sign of social limitation.
In addition to the friendly behavioral patterns, Amy and Tina offered further explanations on the four children’s IF behaviors. The two participants offered three rationales in explaining these behaviors: (a) children’s personalities; (b) their developmental stages; and (c) their desire to have basic needs met. Being an extrovert was linked to children’s friendly behaviors, as Tina expressed that Joshua may be the most extroverted person that she could think of, just based on the fact that he always enjoyed being with people. Both participants defined some of the children’s friendly behaviors as developmentally appropriate. Particularly, expressing a high level of friendliness was not atypical for younger children. In other words, it was reasonable that children under 5 years old consistently exhibited more friendly behaviors than those who were 8 years old or above. Both participants noted that the children mostly regarded themselves as the center of the universe and assumed that others would always be interested to hear everything they had to say. Amy indicated that friendliness may simply serve as a tool for children to have their basic needs met. The friendly tendency was obvious in Beatrice, as whenever she was hungry, she would request food from strangers. Participants did not view this tendency as pathological in speaking of children’s desire to meet their internal drive.
Responses from participants for the quantitative stage echoed the qualitative findings. IF indicators were reinforced by participants’ responses to the 5-item measure. Eighty-five percent of the participants (n = 78) selected 1 for item 1, indicating that their children were friendly (i.e., sometimes or always very friendly) with new adults. Fifty-seven percent of the participants (n = 52) reported the lack of shyness or misbehaving in the presence of strangers. Twenty-five percent of the participants (n = 23) identified 0, meaning “the child has always been shy or behaved in a strange manner,” and approximately 18% (n = 17) indicated that children exhibited a reasonable level of shyness since their arrival in the United States but could not speak to children’s former friendly behaviors back in China.
For item 3, examining children’s behaviors when meeting with new adults, 27% of the participants (n = 25) selected 1, specifying that children always approached new adults, showing toys, speaking or asking questions. About 60% of parents (n = 54) indicated that children would screen new adults (i.e., observing and evaluating) prior to taking actions. The remainder (n = 13; 13%) indicated fears or indifference toward new adults. For item 4, approximately 41% of the participants (n = 38) chose 1, identifying that their children have exhibited some tendency of going home with a newly met adult. With regard to item 5, 23% of the participants (n = 21) reported that their children displayed a tendency to wander, without being subsequently distressed after realizing they were away from their parents.
Research Question 2: What are some potential factors that are associated with IF?
The fourth proposition guiding the qualitative case study was that age, institutionalization, and adoptive parents’ love and responsive parenting were potentially associated with children’s IF behaviors. Amy and Tina asserted that children’s behavioral adjustments were related to children’s ages at the time of arrival in the United States; specifically, younger children demonstrated better behavioral adjustments compared to children adopted at an older age. Comparing the behaviors of Amelia and Beatrice, Amy mentioned that Beatrice, who was adopted at the age of 3, experienced a more challenging time bonding and adjusting in comparison to Amelia, who was adopted at a younger age. Both participants maintained that children adopted at a younger age generally transitioned smoothly and quickly, because children adopted as infants were not old enough to remember their previous experiences, despite the fact that adoption involves separation and loss and itself could be considered as trauma.
The participants connected children’s institutionalization experiences with their later IF behaviors. Children’s IF behaviors were speculated to be a consequence of earlier institutionalization that children had experienced. Amy and Tina viewed IF as one of the institutionalization issues rather than an attachment issue. Amy suggested that children who were previously institutionalized mostly lacked child-parent relationships and failed to form a routine early on in life. It was assessed that something might have happened in children’s brains that made it difficult to learn to interact in later relationships. Tina assumed that Joshua’s IF behaviors represented his life experiences at the orphanage from which he was adopted. She speculated that the overfriendliness had become a pattern in his first three years in the orphanage where he had no clue about whom his next caregiver would be, and a rational way for him to gain attention from others was to be friendly (e.g., giving a hug).
The participants also tied children’s IF behaviors with the news report about suspected child abuse in the orphanage where Joshua was adopted. There was a lack of knowledge and evidence regarding the institutional care that children had received prior to adoption, but the participants held the assumption that children’s weight could be an indicator of the quality of care provided at orphanages, which might be indirectly tied to children’s behaviors of reaching out to strangers for food or other basic needs. All four children’s weight was below the average when adopted, according to the participants. This was the most evident for Joshua, as he weighed only 23 pounds when he was 2 years and 10 months old. His numbers fell off the growth chart for his developmental stage.
Both Amy and Tina highlighted the role of love and responsive parenting as a protective factor of IF behaviors and in counteracting children’s previous institutionalization experiences. In this study, parents’ love and responsive parenting were delivered through understanding of the complexity of IF, accepting the child, and attending to the individual needs of the child. Both participants perceived IF as a concern, yet understood that going through abandonment and institutionalization may have contributed to children’s IF behaviors. Adopting a child meant, according to Amy, not only bringing a child home, but also caring for the child in one’s heart. Strong emotions were provoked when participants recalled children’s atypical experiences compared to their non-adopted peers. The participants reiterated that love should be unconditional to all children, no matter by birth or adoption. Amy firmly believed that whether a child is biological or adopted, it should make no difference in terms of parenting because each child deserves high-quality love. All children should be considered as “our” children, and the love is “our” love.
Separation is what adoptees go through. With strong emotions, Amy highlighted the goodbyes that the adoptees had to say in their lives, all of which apparently were out of their control. Amy elaborated that a child’s life started in the mother’s room for months, and the child was used to the mother’s presence and voice, and then had to tell the mother goodbye. That was the child’s first loss in life. The child was then delivered to the orphanage, labeled as one of many orphans, and taken care of by orphanage staff. Shortly after forming an attachment with orphanage staff and peers (referred to as “crib-mates” by Amy), the child was matched with an adoptive family from overseas and had to say goodbye again. The multiple losses and separations solidified the critical role that adoptive parents may play, so that the child is nurtured in a steady and consistent environment.
Participants believed that showing responsive parenting was vital in helping children work on IF behaviors because changes could not be made on children’s pre-adoption experiences, but could be made on post-adoption caregiving. Tina reinforced that parents should not just take a child away from strangers; a more compelling need for the child was to learn how to act appropriately with strangers. The participants emphasized the importance of selective attending, meaning that parents attend to a child when he/she was in true need (e.g., when a child wanders off without checking in) and ignore behaviors that did not matter to the child’s safety or growth. Participants suggested several techniques for fostering parental attending to children’s needs, including singing children’s tunes, encouraging eye contact, strictly following routines, and offering hugs. These techniques helped instill in the children security and stability.
Age, institutionalization, and love and responsive parenting were included in the quantitative investigation. Bivariate analyses were conducted between each of the variables and IF scores. A higher institutionalization score was significantly correlated with a lower IF score (r = -.24; p < .05); namely, the more positive institutionalization experiences a child had, the fewer IF behaviors the child exhibited (Liu & Hazler, in press). No significant correlations were identified between age and IF (r = -.10; p > .05) or responsive parenting and IF (r = -.04; p > .05). A multiple regression analysis yielded a significant model, with institutionalization as the significant predictor of IF. The results showed that institutionalization explained 9% variance in IF scores (R2 = .09, F (1, 88) = 4.16, p < .05) (Liu & Hazler, in press). Responsive caregiving was nonsignificant in predicting IF.
Research Question 3: Is IF related to children’s attachment?
In answering this question, data were matched with the fifth proposition: there was no clear conclusion on whether children’s IF was related to their attachment to parents, which warrants a further examination of the IF–attachment relationship. Neither qualitative nor quantitative results provided evidence to support a relationship between children’s attachment and IF behaviors. Amy and Tina shared an interesting fact that the children seemed to attach well with them in spite of frequent IF behaviors directed to adults other than the primary caregivers. All four children were reported to form successful attachment with their adoptive parents; in the meantime, they displayed different levels of IF toward strangers. The two participants held the opinion that IF may not necessarily be categorized as an attachment disorder. This was echoed by previous analysis concerning institutionalization, in which parents speculated that IF behaviors might be more appropriately treated as an institutionalization versus attachment issue. Tina disclosed that Joshua’s IF behaviors were described by a clinical practitioner as “nowhere near the attachment disorder.”
A bivariate analysis was conducted between attachment and IF scores using the quantitative data, which yielded a nonsignificant result (r = .12, p > .05). Therefore, no significant correlation was detected between attachment and children’s IF behaviors. A direct interpretation of the quantitative result was that an adoptee’s attachment with adoptive parents was not correlated with the level of the child’s IF. Positive attachment and IF can coexist in a child, which was consistent with the case study findings.
Discussion
This mixed methods study revealed qualitative themes and quantitative evidence in addressing the three research questions. Consistent with previous findings, this study reinforced that IF appears to be a prevalent issue in Chinese adoptees. Children’s IF was demonstrated through quick bonding to new adoptive parents soon after adoption, initiating excessively friendly behaviors to strangers, and responding to strangers’ affectionate behaviors without hesitance. A child’s affectionate behaviors toward adoptive parents were deemed a sign of IF, as the child and adoptive parents did not have previous encounters with each other. Under attachment theory (Bowlby, 1969), a child selectively shows affection to and seeks proximity from the mother or the primary caregiver, and the attachment relationship is based on frequent behavioral exchanges between the child and the mother or primary caregiver (Sroufe & Waters, 1977). Naturally, children’s excessive friendliness to strangers, without the selection process under the attachment theory, is considered atypical behavior.
IF behaviors were described as a manifestation of pathology and either classified as a subtype of attachment disorder under the DSM-IV (APA, 1994) or renamed as disinhibited social engagement disorder in the most recent DSM-5 (APA, 2013). The 5-item IF measure utilized in the study was consistent with the screening questions within the DSM, which concretized the IF through specific behaviors such as wandering off and going home with strangers. Although the items provided a simplified interpretation of IF, qualitative findings revealed multiple layers tied to IF that have not been adequately attended to by researchers and professional practitioners. The DSM-IV and DSM-5 classifications were based on the presumption that IF was an outcome of pathogenic care or maltreatment that children had experienced earlier in life (APA, 1994, 2013).
There has been a lack of investigation into personal factors that may explain children’s IF behaviors. Qualitative findings of this study illuminated the complex nature of IF and directed attention to other alternative criteria, in addition to pathogenic care, including children’s personality types, developmental stage, and drive to meet personal needs. These findings were consistent with Bennett, Espie, Duncan, and Minnis’ (2009) qualitative study that explored IF through children’s lenses. Bennett and colleagues highlighted children’s two internal drives underlying their IF behaviors: seeking love/attention and striving to meet personal needs. A comprehensive literature review by Love, Minnis, and O’Connor (2015) also challenged the pathogenic care criterion within the DSM by proposing several additional factors associated with IF, including genetic differences, inhibitory control, cognitive ability, and post-adoption caregiving.
Children’s former institutionalization experiences were proposed to be a salient factor associated with children’s behaviors (Bruce et al., 2009). The significant role of institutionalization in relation to IF was supported by numerous earlier studies conducted with internationally adopted children (Bruce et al., 2009; van den Dries et al., 2012). IF has been reported as a salient issue with previously institutionalized children in comparison with children raised in their birth families (Chisholm, 1998; Tizard & Hodges, 1978). Findings seem to be unanimously significant across the literature in regards to the association between children’s institutionalized experiences and children’s IF behaviors. The quantitative results of this study echoed previous findings, with institutionalization significantly associated with children’s IF. Qualitative findings also highlighted the role of institutional care as a factor associated with children’s IF behaviors. For example, children who received inadequate care from pre-adoption institutions may appear to be friendlier or seek food and/or attention from adults, as they had to compete with other children in the institution for a limited amount of available resources.
Another variable that revealed inconsistent findings between the qualitative and quantitative datasets was responsive parenting. Quantitative results of this study did not support the significance of caregiving by adoptive parents, which was supported by Zeanah and Smyke (2008), and IF was confirmed not to be associated with post-adoption caregiving quality. Qualitative findings of this study, on the other hand, demonstrated the importance of love and responsive parenting in working with children’s behavioral adjustment. Similar findings can be retrieved from the study by van den Dries et al. (2012), which indicated that children receiving better maternal care after adoption presented less IF behaviors.
The relationship between IF and attachment has been repeatedly investigated in the literature, with two antithetical views: (a) IF is a form/subtype of attachment (APA, 1994; O’Connor et al., 2003); and (b) IF needs to be treated as a unique behavioral issue, separate from attachment (APA, 2013; Lyons-Ruth, Zeanah, & Gleason, 2015). A common theme between the two views is that IF behaviors are developmentally inappropriate. The quantitative results of this study were aligned with the latter view that IF is not significantly correlated with attachment. Qualitative responses from this study were congruent with the quantitative results, as participants indicated that positive attachment and IF behaviors indeed coexist in children. The qualitative findings furthermore challenged the pathological stance that has been historically held about IF, with an alternative explanation that children’s personalities, developmental stages, and internal drives to meet personal needs may be associated with their IF behaviors.
Limitations
This study has three main limitations. The comparatively low Cronbach alpha value of the 5-item IF measure was the first concern, which brought about the question of whether or not the 5-item IF was adequate in measuring IF, although low level of internal consistency is noted to be common in short scales (Streiner, 2003). The second limitation was related to participants and self-report surveys, in which reporter bias and social desirability could confound the results; namely, participants might have chosen to respond to the items based on what they believed to be socially desirable responses. Further, using parents as the only participants is likely to arouse doubt on whether or not parental perceptions of children’s IF behaviors were accurate. The third limitation was related to data saturation. Although sample size is not emphasized in qualitative research, data saturation has been consistently suggested, meaning that data collection should continue until the point that no new information arises. A practical concern is that qualitative results based on the four Chinese adoptees’ experiences may not reach data saturation (Creswell, 2013; Teddlie & Yu, 2007), thus potentially affecting the analytical generalization of qualitative findings. Nevertheless, Teddlie and Yu (2007) offered further justification for the need of representativeness and saturation trade-off sampling in mixed methods research. This sampling technique entails unequal emphases of qualitative and quantitative sampling within a mixed methods study; namely, when quantitative representativeness is emphasized, less emphasis is directed to the qualitative saturation of the study.
Research and Clinical Implications
Results of this study provide crucial implications for future research and practice by professional counselors who work with Chinese adoptees and adoptive parents (e.g., counselors working in school or family settings). Controversies on the categorization of IF (as attachment or other mental health disorders) in the DSM, along with the additional factors proposed by participants, indicate a compelling need to develop a more mature measure for IF, considering a wider range of behaviors beyond the five items. One goal of the new measure is to offer a justification on whether IF truly exists in a child and the severity of the IF tendency. Future research studies should be considered regarding the underlying causes of IF. Researchers should consider involving children in future investigations in order to acquire diverse perspectives on IF and to obtain more generalizable results from the first-person lens.
A clinical implication from this study is that professional counselors working with adoptees and adoptive families need to attend to the complexity of IF. IF behaviors certainly need to be monitored and screened because of the risks associated with the behaviors; however, no quick diagnosis should be reached without adequate evidence on the frequency and magnitude of the behaviors. Practitioners need to reassess the criteria defining pathology—whether or not children’s friendly behaviors are truly indiscriminate and to what extent a friendly behavior should be classified as abnormal (Zeanah & Smyke, 2008). These clinical needs call for practitioners’ familiarity with evidence-based research and more exposure to the target population, IF-related training programs, and a more comprehensive clinical questionnaire asking for further evidence to support children’s IF occurrence and severity.
Conclusion
This study enriched the knowledge of IF through a mixture of qualitative and quantitative findings. Results of this study unveiled Chinese adoptees’ experiences of IF and shed light on factors associated with IF, strengthening the significance of institutionalization as an important factor in children’s IF behaviors. The authors also generated a significant regression model that accounted for 9% of the variance in IF (Liu & Hazler, in press). In alignment with recent research studies (Love et al., 2015; Lyons-Ruth et al., 2015) and the DSM-5, this study provided evidence to support the distinction of IF from attachment. It also introduced alternatives to the pathological perspective toward IF from previous research and diagnostic standards. The results of this study enabled a better understanding of IF and offered research recommendations and critical implications for professional counselors serving adoptive families.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Yanhong Liu, NCC, is an assistant professor and the School Counseling Program Coordinator at The University of Toledo. Dan Li is a doctoral candidate in counselor education at the University of Iowa. Yanqing Xu is an assistant professor at The University of Toledo. Correspondence may be addressed to Yanhong Liu, 2801 W. Bancroft St., MS 119, Toledo, OH 43606, yanhong.liu@utoledo.edu.
Sep 27, 2017 | Book Reviews
Recently, Holland and Messer’s Self-Directed Search (SDS) Form R, 5th Edition was revised and published along with associating forms, formats, and materials. In response to these developments, Reardon and Lenz assembled an updated guide for “practitioners seeking to enhance their use of the SDS or (for) our graduate students learning to be career counselors or advisors” (p. iii). The Handbook that resulted contains a trove of content both applicable for practice and theoretically anchored. Notably, the authors detail a novel approach for interpreting the SDS using Holland’s theory in concert with cognitive information processing (CIP). The following review of the spiral-bound, paperback Handbook begins with a summary of its 12 chapters. Then strengths, limitations, and an overall appraisal of the text are provided.
Chapter 1 presents a candid case study of John Holland’s own RIASEC profile scores, placing his theory and the SDS into greater context. “Experienced SDS users will recognize (Holland) as a case of an undifferentiated, elevated profile” (p. 2). Following such insight into Holland’s personality, tenets of RIASEC theory are outlined (Chapters 2 and 3). In doing so, common myths are addressed, such as the misstatement that “RIASEC types are not applicable to persons of different racial and ethnic heritages” (p. 12).
After RIASEC theory, Reardon and Lenz delve into the SDS as an instrument and career intervention (Chapters 4 and 5). Here, SDS components and their applicability are detailed (e.g., Occupations Finder, Educational Opportunities Finder [EOF], You and Your Career [YYC] booklet). Highlighted too is a much needed Veterans and Military Occupations Finder (VMOF). This new instrument “allows users to better understand how the skills and abilities developed in the military relate to civilian occupations with similar requirements” (p. 67).
Chapters 7–9 explain the CIP model for improving SDS interpretability. As the authors assert, “Using all of the interpretive and diagnostic information provided by the SDS within the context of a CIP-based service delivery system can provide most, if not all, of the critical ingredients in effective career interventions” (p. 95). A career decision-making process derived from CIP, called the CASVE cycle, is explained as being especially beneficial. To further illustrate the synergy between CIP and RIASEC, four SDS case studies are reviewed in Chapter 10. Concluding the book is a discussion of career service models at the programmatic level (Chapter 11), and then future trends in SDS application (Chapter 12).
Through explaining SDS administration and interpretation, Reardon and Lenz effectively link RIASEC and CIP theories to practice. This theory-to-practice linkage was achieved with clever decisions to limit “referencing, statistics, and academic detail” to make content more palatable for practitioners and students (Preface, p. iii). According to the authors, “We were also especially mindful that counselors are primarily SAE (Social, Artistic, Enterprising) types” (Preface, p. iii). As a result, the writing style is refreshingly personable and enriching.
Additionally, a myriad of tables, figures, and case studies are presented throughout the book. There are 29 figures, 14 tables, and 13 appendices to help facilitate SDS interpretation. For instance, Table 3.2 describes career interventions for certain Holland types (p. 24). Other examples include a table for SDS indicators and diagnostic signs, and guidelines for using the SDS in conjunction with the CIP approach is found under Appendix J (p. 214).
Though containing numerous strengths, the Handbook lacks content on special populations, especially people with disabilities. Indeed, the authors discuss the SDS Form E (Easy) as an alternative to Form R (Regular) for those with limited reading skills, and an audiotape version (1990) of Form E is said to be available (p. 71). However, discussion of other testing modifications or accommodations for those with different disabilities is absent. Furthermore, the psychometric properties of Form E receive limited attention. While the authors direct readers to studies in the career literature for Form E with special populations, Reardon and Lenz did not detail the findings (p. 71).
In the book, Reardon quotes a former student who, upon learning Holland’s theory of six personality types and environments, asked cheekily, “Is that all there is to it?” (p. 21). The student’s remark reflects a common misperception that Holland’s theory is too simple. However, Reardon and Lenz perfectly illustrate the simplicity and the complexity of this theory that underpins the SDS. As a result, the Handbook will help practitioners (a) glean maximum information from SDS results, (b) gain an understanding of how RIASEC theory and CIP can inform service delivery, and (c) help improve career outcomes for clients.
Reardon, R. C., & Lenz, J. G. (2015). Handbook for using the Self-Directed Search: Integrating RIASEC and CIP theories in practice. Lutz, FL: PAR.
Reviewed by: Matthew McClanahan, East Carolina University
The Professional Counselor
https://tpcwordpress.azurewebsites.net
Sep 11, 2017 | Volume 7 - Issue 3
Shainna Ali, Glenn Lambie, Zachary D. Bloom
The Sexual Orientation Counselor Competency Scale (SOCCS), developed by Bidell in 2005, measures counselors’ levels of skills, awareness, and knowledge in assisting lesbian, gay, or bisexual (LGB) clients. In an effort to gain an increased understanding of the construct validity of the SOCCS, researchers performed an exploratory factor analysis on the SOCCS with a sample of practicing counselors who were members of the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) and counselors-in-training (N = 155) enrolled in four Council for Accreditation of Counseling & Related Educational Programs (CACREP)-accredited counseling programs. The data analyses resulted in a 4-factor model, 28-item assessment that explained 56% of the variance. In acknowledging the loading of the fourth factor, this result highlights the need to focus on involvement and engagement in clinical practice in order to maintain best practice standards. Furthermore, the fourth factor of experience adds a compelling perspective to consider when understanding, improving, and maintaining sexual orientation counselor competence.
Keywords: sexual orientation, counselor competence, exploratory factor analysis, best practice standards, SOCCS
In order for counselors to be ethical and effective professionals, they must be competent in providing services to sexual minority clients (Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC], 2013). The American Counseling Association’s (ACA) 2014 ACA Code of Ethics requires that counselors honor the uniqueness of clients in embracing their worth, potential, and dignity. Additionally, counselors should actively attempt to understand client identity, refrain from discrimination, and utilize caution when assessing diverse clients (ACA, 2014). Furthermore, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) 2009 Standards for Accreditation assert that counselors should understand identity development, develop self-awareness, promote social justice, and strive to eliminate prejudices, oppression, and discrimination. Therefore, it is both ethical and essential to empirically explore competence assessments in order to improve overall counseling competence.
Sexual minority clients are at risk for a myriad of concerns such as shame, depression, risky behaviors, self-harm, abuse, and suicide (Cooper, 2008; Degges-White & Myers, 2005; Human Rights Campaign, 2014; McDermott, Roen, & Scourfield, 2008). In order to align with the intended population of the Sexual Orientation Counselor Competency Scale (SOCCS; Bidell, 2005), sexual minority clients are defined as individuals who identify as lesbian, gay, or bisexual (LGB). Since the 1970s, researchers have identified the importance of counseling for LGB individuals, as these clients have a higher propensity for suicide and substance abuse as compared to heterosexual populations (Cass, 1983; Cooper, 2008; Degges-White & Myers, 2005; McCarn & Fassinger, 1996; Troiden, 1979, 1989). Furthermore, at the turn of the 21st century, researchers began to note the importance of competence in providing effective counseling services to sexual minority clients (Bidell, 2005; Brooks & Inman, 2013; Graham, Carney, & Kluck, 2012; Grove, 2009; Israel & Selvidge, 2003).
Bidell (2005) developed the SOCCS in an effort to measure counselors’ awareness, skill, and knowledge competencies in assisting LGB clients. Initial research findings supported the criterion, concurrent, and divergent validity, and the internal consistency and test-retest reliability of the SOCCS with the norming population; however, the factor structure (construct validity) of the SOCCS with the norming population was questionable (i.e., 40% of the variance explained by the 29-item SOCCS). Therefore, additional research is warranted to examine the construct validity of the SOCCS with a different sample of counseling professionals, as construct validity provides a central understanding to whether or not the assessment: (a) measures the intended competencies, (b) is adequately explicated by a 3-factor structure, and (c) is best comprised of 29 items (Gall, Gall, & Borg, 2006). Consequently, the purpose of the present study was to examine the factor structure of the SOCCS with a sample of counseling practitioners and counselors-in-training to gain an increased understanding of the construct validity of the SOCCS. The findings of the present study add a new perspective, as the results display a potential 4-factor structure that warrants consideration in the literature.
Sexual Orientation Counselor Competency Scale
The SOCCS (Bidell, 2005) is a 29-item instrument designed to measure counselors’ level of competence in working with clients identifying as LGB. The SOCCS was developed based on the LGB-affirmative counseling and multicultural counseling competencies (Sue, Arredondo, & McDavis, 1992) and included an item pool of 100 items that was reduced to 42 items with 12 items pertaining to skills, 12 items to awareness, and 18 items to knowledge. Bidell (2005) examined the factor structure of the SOCCS using exploratory factor analysis (EFA) with a principal axis factoring (PAF) and an oblique rotation, identifying a 3-factor structure: (a) Factor 1: Skills (11 items, 24.91% of the variance explained), which assesses counseling skills in working with LGB clients; (b) Factor 2: Awareness (10 items; 9.66% of the variance explained), which measures counselors’ awareness of biases and attitudes about LGB individuals; and (c) Factor 3: Knowledge (8 items, 5.41% of the variance explained), which assesses counselors’ understanding about the LGB population.
Factor Analysis
Bidell (2005) also examined the criterion, convergent, and divergent validity of the SOCCS with his sample. Criterion validity of the SOCCS was examined using participants’ education level and self-identified sexual orientation. A positive relationship was identified between the participants’ SOCCS subscale scores and their level of education and sexual orientation. Convergent validity was examined by measuring the relationship between SOCCS subscale scores and participants’ Attitudes Toward Lesbians and Gay Men Scale (Herek, 1998), the knowledge subscale of the Multicultural Counseling Knowledge and Awareness Scale (Ponterotto et al., 1996), and the skills subscale of the Counselor Self-Efficacy Scale (Melchert, Hays, Wiljanen, & Kolocek, 1996). The results of the correlational analyses supported the convergent validity of the SOCCS. Discriminant validity was examined by comparing the mean social desirability scores with the SOCCS subscale scores, and results supported the divergent validity of the SOCCS within the norming sample.
Norming Population of the SOCCS
The norming population for the SOCCS (Bidell, 2005) consisted of 312 mental health students, providers, and educators from across the United States. The majority of the sample was comprised of females (n = 235) and the average age was 31.9 years old. Individuals were recruited from 13 public and three private universities. More than 80% of the population included students: (a) 47 were undergraduates from an undergraduate introduction to counseling course, (b) 154 were master’s- level students in school or community counseling programs accredited by CACREP, (c) 32 were doctoral students from a CACREP-accredited counselor education program, and (d) 30 were from university internship sites approved by the American Psychological Association. The non-student portion of the population was comprised of 49 doctoral-level counselor education supervisors. A majority of the population (85.5%) identified as heterosexual, 12.2% identified as LGB, and 2.5% chose to not identify. Bidell (2005) noted the limited gender variance in the development of the SOCCS, as it is possible that individuals within the 2.5% may identify on the gender continuum. More than half of the norm group (n = 191) identified as European American or White, 41 as Latino, 32 as Asian American, 22 as African American or Black, seven as biracial or mixed, and four as Native American. Fourteen individuals identified as “other,” and this may have been because of rigid racial denominations provided in the demographics.
Interpretation of the SOCCS
The SOCCS (Bidell, 2005) is a criterion-referenced measure consisting of rating scales. The SOCCS provides respondents with a range of seven choices to self-report on the three subscale domains (Skills, Awareness, and Knowledge): from (a) not at all true, to (b) moderately true, and to (c) totally true. Eleven of the 29 SOCCS items (2, 10, 11, 15, 17, 21, 22, 23, 27, 28, and 29) are reverse scored, and overall competence is interpreted by the sum of the items divided by the total number of items (29) to form a percentage score. Bidell (2005) does not provide information on criteria to determine low, moderate, or high competence; however, inferences can be made from interpreting the overall and subscale scores (Farmer, Welfare, & Burge, 2013).
The overall mean SOCCS (Bidell, 2005) score in the norm group was 4.64 (SD = 0.89). Subscale mean SOCCS scores included 2.94 (SD = 1.53) for Skills, 6.49 (SD = 0.79) for Awareness, and 4.66 (SD = 1.05) for Knowledge. Graham, Carney, and Kluck (2012) sampled 234 counseling students and found mean SOCCS averages for competence were 3.88 for Factor 1: Skills, 6.52 for Factor 2: Awareness, 4.67 for Factor 3: Knowledge, and 5.01 for overall SOCCS scores. Follow-up studies continue to support the original theme in which individuals believe they are more aware but less knowledgeable; furthermore, individuals believe they have less skills than knowledge pertaining to sexual minority counselor competencies (Bidell, 2012; Farmer et al., 2013; Grove, 2009; Rutter, Estrada, Ferguson, & Diggs, 2008).
In addition, Graham and colleagues (2012) also assessed for potential differences in SOCCS scores between individuals who have or have not attended a conference presentation, workshop, or training pertaining to LGB issues. No difference in SOCCS scores was identified between participants reporting that they attended a conference presentation with subject matter pertaining to LGB counseling or not; however, individuals who attended a workshop had higher competency scores in Skills, F (1, 225) = 61.03, p < .001; Awareness, F (1, 225) = 4.42, p < .05; and Knowledge, F (1, 225) = 4.34, p < .05. Additionally, individuals who attended a training session had higher scores in the domains of Skills, F (1, 225) = 32.07, p < .001; Awareness, F (1, 225) = 33.62, p < .001; and Knowledge, F (1, 225) = 33.62, p < .001; and when compared to individuals who did not attend similar trainings. Furthermore, more experience with LGB clients yielded higher competency scores. A Tukey’s post hoc analysis identified that individuals who had never provided counseling services to LGB clients had lower SOCCS scores (M = 4.43, SD = 0.72) than individuals who had provided services to one to five LGB clients (M = 4.99, SD = 0.66), six to 10 LGB clients (M = 5.57, SD = 0.55), 11 to 15 LGB clients (M = 5.59, SD = 0.57), or more than 15 LGB-identified clients (M = 5.78, SD = 0.50). Therefore, the differences in SOCCS scores suggest that more exposure and experience with LGB clients could improve sexual minority counseling competence.
Factor Analysis of the Original Instrument
The SOCCS (Bidell, 2005) coefficient alpha for internal consistency reliability was found to be .90. The subscale scores for internal consistency were .91 for Skills, .88 for Awareness, and .71 for Knowledge. A subsection of the sample (n = 101) including students and supervisors was used for test-retest reliability. One-week test-retest reliability was found to be .84 for the overall instrument, .83 for the Skills subscale, .85 for the Awareness subscale, and .84 for the Knowledge subscale (Bidell, 2005). In addition, Bidell (2013) investigated the potential for SOCCS scores to change after implementation of an LGB counseling course six weeks into the program, and identified that the participants’ scores were significantly higher on the overall and subscale scores. Bidell’s (2013) findings identified the ability for education to promote SOCCS scores in counseling students but challenged the test-retest reliability of the SOCCS. No published data was identified related to the inter-rater reliability or alternate forms of the SOCCS.
Additional Factor Analysis of the SOCCS
Carlson, McGeorge, and Toomey (2013) examined the factor structure of the SOCCS with a sample of 248 master’s and doctoral students in couple and family therapy and identified a 2-factor solution: (a) Factor 1: Awareness and (b) Factor 2: Knowledge and Skills. Further, three SOCCS items (i.e., 5, 24, 25) did not load into the combined Knowledge and Skills subscale and were removed. The second examination resulted in an acceptable model fit x2 (df = 8) = 20.65, p < .01; however, it should be noted that five SOCCS item stems (i.e., 3, 4, 7, 8, 19) were altered and the 7-point scale was adapted to a 6-point scale. Therefore, based on the modifications made to the SOCCS, it is difficult to compare the factor structure results to other investigations using the unmodified SOCCS.
Counseling Competency With Sexual Minority Clients
Researchers have utilized the SOCCS in an effort to further their understanding of counseling competencies related to working with sexual minority clients (Brooks & Inman, 2013; Graham et al., 2012; Grove, 2009). Grove (2009) provided counseling students (n = 56) with the SOCCS, and an ANOVA identified that years in training provided a significant difference in scores for Skills (p = .002), Awareness (p = .05), and Knowledge (p = .001). Although analyses were not conducted to determine the differences between subscales, Grove noted high scores in the Awareness subscale. Although individuals have strong, affirmative attitudes, they may lack the knowledge and subsequent skills necessary to effectively aid LGB clients. These SOCCS scores may be interpreted to show a variety of concerns such as inflated confidence, potential lack of training, and low competency. Graham and colleagues (2012) utilized the SOCCS with counselor education and counseling psychology graduate students (n = 234) and yielded similar results to Grove. Participants scored highest on the Awareness subscale, followed by the Knowledge and Skills subscale scores. These research findings identify that counselor trainees may not be receiving the necessary knowledge and skills to become competent counselors in working with sexual minority clients.
Advances have been made in the counseling field regarding the understanding of competency in aiding sexual minority clients (Bidell, 2005; Graham et al., 2012; Grove, 2009); however, additional research is warranted. The commonly utilized SOCCS is a self-report measure; therefore, there is potential for participants to provide socially desirable answers. Further, because the SOCCS was created to measure counselors’ level of confidence (self-efficacy) in providing counseling services to LGB clients, the literature has followed this narrow lead (Bidell, 2013; Carlson et al., 2013; Grove, 2009) . The SOCCS was created prior to ALGBTIC’s (2013) guidelines; therefore, the items may not align with the essential aspects of the guidelines. Considering this potential gap, it is essential to explore the psychometric properties of the SOCCS (Bidell, 2005). Nevertheless, the SOCCS is the most used assessment instrument for examining LGB counselor competence in training and research; hence, it is important to explore the reliability and validity of the instrument in order to support continued exploration of LGB counselor competence. Therefore, we aimed to examine the factor structure of the SOCCS with a sample of counselor trainees and practitioners in order to gain an increased understanding of the psychometric properties of this assessment. The following research questions guided our investigation:
Research Question 1. What is the factor structure of the SOCCS with a sample of practicing counselors and counselors-in-training?
Research Question 2. What is the internal consistency reliability of the SOCCS with a sample of practicing counselors and counselors-in-training?
Method
Participants
We aimed to examine the factor structure of the SOCCS with a sample of practicing counselors and counselors-in-training. The data used for this investigation were part of a larger study regarding counselors’ preparedness to assist clients in the coming-out process. Because online surveys tend to have a lower response rate (Shih & Fan, 2009), we decided to use additional intentional data collection methods in our sampling to achieve a sample of counselors-in-training and practicing professionals. The data collection assessments were distributed through ALGBTIC in order to acquire a national sample of counseling professionals and to include individuals who may perceive themselves as competent to work with sexual minority individuals. In addition, the data collection assessments were distributed to counselors-in-training enrolled in four CACREP-accredited counseling programs in four different southeastern states with the assumption that the student population would help to cover the domain of individuals who do not believe they are competent to assist sexual minority clients in counseling. We received a total of 200 responses, which gave us a response rate of 28.41%. However, because of missing data, 45 participants were eliminated, leaving 155 (22.02%) usable cases. Although the response rate was less than the weighted average Van Horn, Green, and Martinussen (2009) noted in their meta-analysis of counseling and clinical psychology journals (49.6%), we decided our response rate was adequate to continue because of the necessity of research on the factor structure of the SOCCS and the potential value of the implications on improving counseling services for sexual minority clients. Additionally, the demographics of the sample mirrored the overall population (i.e., a majority of the participants identified as white and female), which is presented in Table 1 (U.S. Census Bureau, 2016).
Procedure
Our university’s institutional review board approved this study prior to any data collection and recruitment. We implemented the Tailor Design Method (Dillman, Smyth, & Christian, 2009) in our recruitment and data collection (e.g., invitation, survey). We utilized Qualtrics, an electronic survey research tool, to assemble our informed consent, data collection instruments, and demographic questionnaire online. Qualtrics permitted us to collect anonymous data. After data collection, Statistical Package for the Social Sciences (Windows Version 20) was used for data cleaning and analysis.
Data Screening
Before we analyzed our data, we screened our dataset. First, we needed to remove responses with at least one incomplete item from the overall data set to promote consistency (Warner, 2013). Listwise deletion resulted in the removal of 45 cases, resulting in 155 completed data collection packets for the investigation. SOCCS item scores were converted to standardized z-scores to determine if outliers
Table 1
Participants’ Demographic Characteristics
Characteristic n Total Percent
Gender
Female 121 82.9
Male 24 16.4
Ethnic Background
African American/African/Black 14 9.7
Asian/Asian American 6 3.9
Biracial/Multiracial 9 5.8
Caucasian (Non-Hispanic) 105 67.7
Hispanic/Latina/Latino 7 4.5
Other 2 1.3
Chose not to specify 2 1.3
Sexual Orientation
Bisexual 8 5.2
Gay 5 3.2
Heterosexual 71 45.8
Lesbian 7 4.5
Other 3 1.9
Professional Status
Student 102 61.5
Clinician 43 33.3
CACREP Status
Accredited 73 46.8
Not Accredited 20 12.8
Age
21–25 70 45.2
26–30 27 17.4
31–35 16 10.3
36–40 13 8.4
41–45 4 2.6
46–50 7 4.5
51–55 1 .6
56–60 6 3.9
61–65 1 .6
Note. N = 155
existed in the data, and the results identified that no scores were greater than +4 or less than -4; therefore, no outliers were identified (Hair, Black, Babin, Anderson, & Tatham, 2010). Next, we examined the appropriateness of the sample size to conducting an EFA. Smaller sample sizes are suitable for EFA if several solutions have high loading variables (above .80; Tabachnick & Fidell, 2013). In addition, rather than sample size, the ratio of assessment items to participant may be used to determine appropriateness of data for EFA (Dimitrov, 2012; Nunnally, 1978; Tabachnick & Fidell, 2013), with a five participant cases-to-item ratio deemed acceptable. Because there were more than five cases per SOCCS item (5.34:1), we determined this sample size was appropriate for EFA. Our next step was to examine the normality of the data and determine the most appropriate method of extraction. To assess for normality of our data, we checked the univariate normality of each SOCCS item, and if item univariate normality was satisfied, we checked multivariate normality using the Mardia test (Mvududu & Sink, 2013). We identified several SOCCS items that were not normally distributed; therefore, multivariate normality was not examined because univariate normality is a necessary condition of multivariate normality (Mvududu & Sink, 2013). In addition, our histograms, boxplots, and Q-Q Plots results identified that multiple SOCCS items were non-normally distributed; hence, we assumed the data was non-normally distributed, which can occur in social science research (Mvududu & Sink, 2013).
Data Analysis
After screening the dataset for missing data and assessing for normality, we conducted an EFA to examine the factor structure of the SOCCS with our sample of counseling practitioners and counselors-in-training. Because of the non-normality of the data (Costello & Osborne, 2005), PAF was used for extraction with an oblimin rotation with Kaiser Normalization. A significant value (p < .001) was identified for Bartlett’s test of sphericity (Bartlett, 1954), and a value of .83 was obtained for Kaiser-Meyer-Olkin sampling adequacy for the SOCCS. Next, we examined internal consistency reliability of SOCCS using Cronbach’s α, thus assessing the degree of correlation between SOCCS items.
Results
To examine the factor structure of SOCCS, we used EFA, employing PAF analysis. All SOCCS items displayed a factor loading of at least .3 and were initially retained (Floyd & Widaman, 1995; Hair et al., 2010). However, SOCCS items were reduced following classical test theory in order to reduce items with poor measurement properties and to increase internal consistency reliability (Crocker & Algina, 2006; DeVellis, 2003). As noted in Table 2, The PAF results identified the presence of six SOCCS factors with eigenvalues exceeding one, explaining 62% of the variance. However, the first three factors produced eigenvalues of greater than 2.8, whereas the remaining three were all less than 1.5. The three factors accounted for 49% of the variance. As noted in Figure 1, the scree plot, a preferred method for identifying factor solutions in EFA (Hair et al., 2010), identified a steep decline including three factors, a break near the fourth factor, and a significant plateau at the fifth factor, supporting a 3- or 4-factor model solution for the SOCCS with these data. The factor matrix showed loadings of more than .4 for the first three factors, and less than .4 for the fourth through sixth factors. The first three SOCCS factors paralleled Bidell’s conceptually based factors of Skills, Awareness, and Knowledge. In the essence of EFA, we examined the potential construct being measured by the fourth factor and determined that all items (i.e., 4, 7, 8, 12 and 18) pertained to experience. Originally, these SOCCS items were included in the Skills subscale; however, we determined that the presence of these items together shows promise for a fourth SOCCS subscale of Experience. The model with four subscales accounted for 54% of the variance.
The Knowledge subscale was the only subscale that loaded as intended with eight items, accounting for 9.90% of variance as compared to 5.41% of variance in the original analysis (Bidell, 2005). Six SOCCS items loaded onto the Skills subscale, accounting for 27.5% of the variance as compared to 24.91% of variance in the original analysis. The remaining five SOCCS items that did not load onto the Skills subscale loaded together onto the fourth subscale, which is the Experience subscale. The Experience subscale accounted for 5.11% of the variance. Five SOCCS items loaded onto
the Awareness subscale. Of the remaining items, three loaded onto both fifth and sixth factors (i.e., 11, 15, and 17). Unlike the Awareness subscale, which was theoretically justified, a fifth factor was not theoretically justified; therefore, we decided to keep these three items with the Awareness subscale.
| Table 2Total Variance Explained |
| Factor |
Initial Eigenvalues
|
Extraction Sums of
Squared Loadings
|
Rotation Sums of Squared Loadings a
|
|
Total
|
% of Variance
|
Cumulative %
|
Total
|
% of Variance
|
Cumulative %
|
Total
|
| 1 |
7.705
|
26.568
|
26.568
|
7.344
|
25.311
|
25.311
|
5.422
|
| 2 |
3.722
|
12.834
|
39.402
|
3.263
|
11.250
|
36.561
|
3.520
|
| 3 |
2.828
|
9.750
|
49.152
|
2.365
|
8.155
|
44.717
|
3.982
|
| 4 |
1.442
|
4.972
|
54.124
|
1.005
|
3.464
|
48.181
|
5.050
|
| 5 |
1.195
|
4.121
|
58.245
|
.710
|
2.447
|
50.628
|
2.362
|
| 6 |
1.088
|
3.752
|
61.996
|
.601
|
2.072
|
52.699
|
1.440
|
| 7 |
.992
|
3.419
|
65.416
|
|
|
|
|
| 8 |
.929
|
3.204
|
68.619
|
|
|
|
|
| 9 |
.898
|
3.097
|
71.716
|
|
|
|
|
| 10 |
.827
|
2.850
|
74.566
|
|
|
|
|
| 11 |
.745
|
2.568
|
77.134
|
|
|
|
|
| 12 |
.705
|
2.431
|
79.565
|
|
|
|
|
| 13 |
.666
|
2.298
|
81.863
|
|
|
|
|
| 14 |
.583
|
2.012
|
83.874
|
|
|
|
|
| 15 |
.540
|
1.861
|
85.735
|
|
|
|
|
| 16 |
.523
|
1.804
|
87.539
|
|
|
|
|
| 17 |
.474
|
1.634
|
89.173
|
|
|
|
|
| 18 |
.445
|
1.535
|
90.709
|
|
|
|
|
| 19 |
.399
|
1.377
|
92.085
|
|
|
|
|
| 20 |
.381
|
1.313
|
93.399
|
|
|
|
|
| 21 |
.341
|
1.174
|
94.573
|
|
|
|
|
| 22 |
.299
|
1.031
|
95.604
|
|
|
|
|
| 23 |
.276
|
.953
|
96.557
|
|
|
|
|
| 24 |
.257
|
.887
|
97.444
|
|
|
|
|
| 25 |
.226
|
.781
|
98.224
|
|
|
|
|
| 26 |
.194
|
.670
|
98.895
|
|
|
|
|
| 27 |
.137
|
.472
|
99.366
|
|
|
|
|
|
| 28 |
.126
|
.434
|
99.800
|
|
|
|
|
|
| 29 |
.058
|
.200
|
100.000
|
|
|
|
|
|
| Note: Extraction Method: Principal Axis Factoring. |
a. When factors are correlated, sums of squared loadings cannot be added to obtain a total variance.
Figure 1.
Eigenvalues from 28-item SOCCS Factor Analysis
Because SOCCS items 10 and 23 only loaded onto factors five and six and no other factor, we decided to remove these items for parsimony. Therefore, the Awareness subscale now has eight items, accounting for 13% of the variance. Further information on factor loadings can be seen in Table 3.
Internal Consistency Reliability of the SOCCS
The second research question examined the internal consistency reliability of the SOCCS with a sample of counselors-in-training and practicing counselors. The original 29-item SOCCS displayed a strong reliability score with a Cronbach’s α of .90 (Leech, Onwuegbuzie, & O’Connor, 2011). As a 27-item assessment, the Cronbach’s α for the overall SOCCS was .894; although slightly lower than the original assessment, the reliability of the revised SOCCS displays strong internal consistency (Leech et al., 2011). Original SOCCS subscale reliability scores were .91 for Skills, .88 for Awareness, and .76 for Knowledge. Our item analysis of the SOCCS data identified strong internal consistency reliability with a Cronbach’s α of (a) Total SOCCS scores .893, (b) SOCCS Knowledge subscale scores .807, (c) SOCCS Skills subscale scores .877, (d) SOCCS Awareness subscale scores .814, and (e) SOCCS Experience subscale scores .872 (Ponterotto & Ruckdeschel, 2007).
Table 3
Factor Loadings for a 4-Factor Solution
| SOCCS Item |
|
|
|
|
|
1
|
2
|
3
|
4
|
| I have received adequate clinical training and supervision to counsel lesbian, gay, and bisexual (LGB) clients. |
.742
|
.255
|
.216
|
.356
|
| I check up on my LGB counseling skills by monitoring my functioning/competency—via consultation, supervision, and continuing education. |
.618
|
.214
|
.365
|
.418
|
| I feel competent to assess the mental health needs of a person who is LGB in a therapeutic setting. |
.925
|
.224
|
.369
|
.588
|
| I have done a counseling role-play as either the client or counselor involving an LGB issue. |
.513
|
.138
|
.317
|
.470
|
| Currently, I do not have the skills or training to do a case presentation or consultation if my client were LGB. |
.673
|
.326
|
.185
|
.533
|
| The lifestyle of an LGB client is unnatural or immoral. |
.173
|
.896
|
-.120
|
.133
|
| I believe that being highly discreet about their sexual orientation is a trait that LGB clients should work toward. |
.132
|
.207
|
.083
|
-.088
|
| I believe that LGB couples don’t need special rights (domestic partner benefits, or the right to marry) because that would undermine normal and traditional family values. |
.171
|
.426
|
.089
|
.127
|
| It would be best if my clients viewed a heterosexual lifestyle as ideal. |
.090
|
.393
|
-.020
|
.109
|
| I think that my clients should accept some degree of conformity to traditional sexual values. |
.102
|
.343
|
.004
|
.040
|
| I believe that LGB clients will benefit most from counseling with a heterosexual counselor who endorses conventional values and norms. |
.050
|
.200
|
.080
|
.163
|
| Personally, I think homosexuality is a mental disorder or a sin and can be treated through counseling or spiritual help. |
.328
|
.618
|
.046
|
.096
|
| I believe that all LGB clients must be discreet about their sexual orientation around children. |
.115
|
.506
|
-.040
|
.010
|
| When it comes to homosexuality, I agree with the statement: “You should love the sinner but hate or condemn the sin.” |
.289
|
.894
|
-.091
|
.180
|
| LGB clients receive less preferred forms of counseling treatment than heterosexual clients. |
.090
|
-.118
|
.584
|
.038
|
| I am aware some research indicates that LGB clients are more likely to be diagnosed with mental illnesses than are heterosexual clients. |
.468
|
.064
|
.581
|
.334
|
| Heterosexist and prejudicial concepts have permeated the mental health professions. |
.300
|
.129
|
.787
|
.202
|
| There are different psychological/social issues impacting gay men versus lesbian women. |
.098
|
-.093
|
.482
|
.202
|
| I am aware of institutional barriers that may inhibit LGB people from using mental health services. |
.524
|
.171
|
.684
|
.334
|
| I am aware that counselors frequently impose their values concerning sexuality upon LGB clients. |
.394
|
-.023
|
.758
|
.195
|
| Being born a heterosexual person in this society carries with it certain advantages. |
.216
|
.040
|
.636
|
.112
|
| I feel that sexual orientation differences between counselor and client may serve as an initial barrier to effective counseling of LGB individuals. |
.038
|
-.220
|
.482
|
-.055
|
| At this point in my professional development, I feel competent, skilled, and qualified to counsel LGB clients. |
.904
|
.310
|
.301
|
.659
|
| I have experience counseling lesbian or gay couples. |
.440
|
.169
|
.147
|
.720
|
| I have experience counseling lesbian clients. |
.494
|
.178
|
.199
|
.847
|
| I have been to in-services, conference sessions, or workshops which focused on LGB issues (in Counseling, Psychology, Mental Health). |
.397
|
.261
|
.192
|
.540
|
| I have experience counseling bisexual (male or female) clients. |
.479
|
.181
|
.179
|
.891
|
Discussion
The purpose of this research was to explore the factor structure and reliability of the SOCCS with a sample of counselor trainees and practitioners in the United States. Our results identified a 4-factor SOCCS model, including the subscales of Skills, Awareness, Knowledge, and Experience. The 4-factor SOCCS structure identified with these substantiate the three previous factors of Skills, Awareness, and Knowledge; however, an additional factor is noted. The fourth factor, Experience, echoes Graham and colleagues’ (2012) findings, which note improved competence with practice. Hence, the results of this study should encourage researchers to explore beyond the 3-factor model and promote measurement versatility with counselor trainees and clinicians. Overall, our results identified a 4-factor SOCCS model with strong internal consistency, offering counselor educators and practitioners a sound method for assessing sexual orientation counselor competence.
Implications for Counselors and Counselor Educators
Counselor competency with sexual minority clients is essential in counselor education (ACA, 2014; ALGBTIC, 2013; CACREP, 2009). Our findings support the use of the SOCCS as a valid and reliable measure of sexual orientation counselor competency. Therefore, we suggest that the SOCCS may be implemented in counselor training programs to assess trainees’ levels of competency in providing services to sexual minority clients. Our results identified that in addition to the previously suggested areas of importance in sexual orientation counselor competence (i.e., Skills, Awareness, Knowledge), experience may be an important factor to consider. Counselor educators may consider methods of facilitating experiences within training in order to foster increases in competence. Further, the SOCCS may be used as a pedagogical intervention strategy in counselor education programs. For example, the SOCCS may be given to students to prompt reflection on overall and subscale competence levels regarding counseling sexual minority clients. The SOCCS may also be used beyond counselor education programs to assure that practicing counselors not only have, but also maintain necessary components of competence in order to aid sexual minority clients. Additionally, the results of our study help to further sexual minority counselor competence literature. The SOCCS (Bidell, 2005) is an effective measure for researchers to employ to examine counselors’ self-perceived levels of competence in working with LGB clients; however, the SOCCS also offers educators and practitioners a tool to support best practices in counseling and counselor education. Our SOCCS data yielded a potential fourth factor (i.e., Experience) that was not delineated as an essential component of counselors’ competence in working with LGB clients in prior research. Therefore, this study prompts researchers, counselor educators, and counselors to consider the factor of counselors’ experience in providing services to LGB clients as a necessary domain of counselor competence.
Recommendations for Future Research
The SOCCS is an effective instrument in assessing sexual orientation counselor competence. At this time, there is no indication of cutoff scores that determine appropriate levels of counselor competence (e.g., counselor is competent or not competent to provide services to sexual minority clients). Hence, we recommend that future researchers investigate levels of competence that should be assessed as benchmarks for counselors-in-training prior to graduating from their graduate programs. To our knowledge, other than the SOCCS creator (Bidell, 2005), Carlson and colleagues (2013) are the only researchers to explore the factor structure of the SOCCS. However, Carlson and colleagues altered SOCCS item stems (i.e., 3, 4, 7, 8, and 19) in their investigation and transformed the 7-point scale to a 6-point scale. Their results displayed a 2-factor model that differs from the 3-factor model recommended by Bidell (2005); however, the amendments to the instrument make the SOCCS results difficult to compare to other studies. Further, to our knowledge, we are the only researchers to explore the factor structure of the SOCCS without altering the instrument prior to exploration. Moreover, our 4-factor SOCCS model results accounted for a larger percent of variance (56%) than the original 3-factor SOCCS model (40%; Bidell, 2005). We recommend that future researchers conduct confirmatory factor analyses with their data to determine if the four factors found in our results are consistent with other samples and populations.
Limitations
We recognize that our study has limitations. The SOCCS is a self-report instrument, making the data vulnerable to social desirability bias (Gall et al., 2006). Our response rate may have contributed to our sampling and data collection methods (e.g., online survey), influencing the external validity of our findings. Because of recruitment from ALGBTIC, it is possible that there may have been bias, as members of this group may not have competence levels that are equivalent to the general counseling population. Additionally, because of an error in the original Qualtrics survey, complete SOCCS answers were not required, thus causing issues in missing data. Furthermore, our sample size was limited, affecting the interpretation of our findings. Nevertheless, our study examined an area warranting further investigation (counselors-in-training’s and counselors’ competency in providing service to sexual minority clients) and offered meaningful findings (e.g., a 4-factor SOCCS model).
Conclusion
The social climate for sexual minorities is changing, and it is imperative for counselors to be competent to serve this population. Because of constant societal change, it is important for measures to be relevant in order to measure sexual minority counselor competence. The SOCCS (Bidell, 2005) is the most current and related instrument to measure sexual minority counselor competence. It fulfills an area of need in counselor training and development. This study provides helpful data to expand on the reliability and validity data of this useful assessment.
Moreover, the findings from the study present the case for a potential fourth subscale of Experience to be considered in addition to Skills, Awareness, and Knowledge. The existence of an additional factor pertaining to involvement and engagement in practice holds considerable implications for counselor training and effective practice with LGB clients.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Shainna Ali, NCC, is an instructor at the University of Central Florida. Glenn Lambie is a professor at the University of Central Florida. Zachary D. Bloom is an assistant professor at Northeastern Illinois University. Correspondence can be addressed to Shainna Ali, 4000 Central Florida Blvd., Orlando, FL 32816, Shainna.ali@ucf.edu.
Aug 27, 2017 | Volume 7 - Issue 3
Carrie Sanders, Laura E. Welfare, Steve Culver
Students in K–12 schools benefit from career counseling as a means to improve their readiness for academic and career success. This quantitative study explored the career counseling self-efficacy of 143 practicing middle school counselors using the Career Counseling Self-Efficacy Scale-Modified and a subscale of the School Counselor Self-Efficacy Scale. Although school counselors were confident overall, evidence of specific areas of concern and limited time for career counseling was found. Results related to the importance of prior teaching experience in relation to career counseling self-efficacy also were highlighted. Implications for school counselors and policymakers include examining the amount of time school counselors spend on providing career counseling in comparison to time spent on non-counseling–related duties.
Keywords: career counseling, middle schools, school counselors, self-efficacy, time
All students in K–12 do not have the same exposure to career opportunities. Providing avenues for students to learn about and identify ways to access a variety of careers is the responsibility of counselors in the school setting. School counselors contribute to students’ development in the domains of academic, career, and social and emotional development through comprehensive school counseling programs (American School Counselor Association [ASCA], 2014). ASCA published ASCA Mindsets and Behaviors for Student Success: K–12 College and Career Readiness Standards for Every Student (2014), which offers a framework of desired mindsets and behaviors for college and career readiness. This resource and others highlight the importance of a school counselor’s work in the career domain. However, school counselors’ knowledge and self-efficacy in the career counseling field may impact their ability to be effective in this aspect of their work (O’Brien, Heppner, Flores, & Bikos, 1997; Perrone, Perrone, Chan, & Thomas, 2000). This quantitative study explored the career counseling self-efficacy of practicing middle school counselors. As students move through elementary and secondary school, they continuously learn valuable knowledge and skills to explore postsecondary options and prepare to enter into the world of work. Middle school is an important time in this continuum for students as they consider their future academic and career plans and identify pathways to achieve their goals. The results of this study, as well as results related to the amount of time middle school counselors spend providing career counseling, yielded valuable implications for school counselors, K–12 stakeholders, and counselor educators.
The Importance of Career Counseling
Students begin to develop career awareness in elementary school, explore careers during middle school, and move into career preparation and planning in high school. Career counseling connects the experiences students have in school to their future, which enhances academic motivation and provides meaning to and purpose for the work they are doing in school (Curry, Belser, & Binns, 2013; Scheel & Gonzalez, 2007). As children and adolescents learn about themselves and the world of work, they are more likely to make informed career decisions, value school, succeed academically, and engage in school offerings (Kenny, Blustein, Haase, Jackson, & Perry, 2006; Orthner, Jones-Sanpei, Akos, & Rose, 2013; Perry, Liu, & Pabian, 2010).
Career counseling is needed in middle school in order to inspire young adolescents to make preliminary career decisions, to prepare them to take desired high school classes, and to equip them for future career pathways (Akos, 2004; Osborn & Reardon, 2006). Curriculum that integrates postsecondary college and career options in middle school has the potential to provide support and motivation for students (Curry et al., 2013). This type of curriculum connects directly to the comprehensive school counseling program. In schools with fully implemented comprehensive counseling programs that include career counseling, students self-reported higher grades, perceived they are better prepared for the future, recognized the relevance of school, and experienced a sense of belonging and safety, more so than in schools with less comprehensive school counseling programs (Lapan, Gysbers, & Petroski, 2001; Lapan, Gysbers, & Sun, 1997). In summary, establishing connections between a student’s academic preparation and possible career options benefits students in various ways, and school counselors are essential guides in the career exploration process.
Career Counseling in Schools
Despite this empirical evidence of its importance (Anctil, Smith, Schenck, & Dahir, 2012; Barker & Satcher, 2000; Osborn & Baggerly, 2004), school counselors can face barriers to implementing career counseling, including limited time because of competing demands, negative perceptions about career counseling, and low school counselor self-efficacy. For example, school counselors are often called upon to perform non-counseling tasks that take time away from providing a comprehensive school counseling program. School counselors desire to be engaged in promoting positive student outcomes and would prefer to spend less time on non-counseling–related activities (Orthner et al., 2013; Scarborough & Culbreth, 2008). There is some evidence that the desire to spend more time on counseling applies directly to career counseling, as found in a study of school counselors at all levels (Osborn & Baggerly, 2004). But, other studies have found that some school counselors are uncertain about the importance of career counseling (Perrone et al., 2000). These findings may indicate that although there is a desire to spend more time providing career counseling, there is uncertainty about its value.
Another potential barrier that is a focus of this study is individual school counselor self-efficacy. Self-efficacy, a core construct in this study, centers on the belief one has in his or her ability to perform a task (Bandura, 1986, 1997; Eccles & Wigfield, 2002). Self-efficacy of school counselors would be defined as beliefs about their abilities to provide effective counseling services (Larson & Daniels, 1998). High self-efficacy among school counselors would promote adaptive delivery of school counseling services to meet the needs of diverse student populations (Bodenhorn & Skaggs, 2005; Larson & Daniels, 1998). Social cognitive career theory (Lent & Brown, 2006; Lent, Brown, & Hackett, 2000) offers a framework for understanding self-efficacy in action—that is, how it impacts the interactions between individuals, their behaviors, and their environments. O’Brien and Heppner (1996) explored social cognitive career theory as it applies to interest, engagement, and performance of career counseling.
The interaction between people, their behavior, and their environment provides a highly dynamic relationship. Performance in educational activities is the result of ability, self-efficacy beliefs, outcome expectations, and established goals. School counselors have varied training experiences and personal self-efficacy beliefs that impact the delivery of a career counseling program. A school counselor’s self-efficacy in career counseling can increase through four primary sources: personal performance, vicarious learning, social persuasion, and physiological and affective states (Bandura, 1997). School counselor self-efficacy may be influenced by many things such as graduate training, service learning, internships, professional development, and years of experience (Barbee, Scherer, & Combs, 2003; Lent, Hill, & Hoffman, 2003; O’Brien et al., 1997). Teaching is a related experience that may impact career counseling self-efficacy. Some authors have highlighted prior teaching experience as helpful in the preparation of school counselors; others have not found such evidence (Baker, 1994; Peterson & Deuschle, 2006; Smith, Crutchfield, & Culbreth, 2001). Skills school counselors use to provide classroom guidance, which is one delivery method for career counseling services, are similar skills to those used by effective teachers (Akos, Cockman, & Strickland, 2007; Bringman & Lee, 2008; Peterson & Deuschle, 2006), so it is reasonable to expect that school counselors without teaching experience may be less comfortable managing a classroom of students than those with teaching experience (Geltner & Clark, 2005; Peterson & Deuschle, 2006).
There are two studies that have explored self-efficacy of school counselors with and without prior teaching experience. Scoles (2011) compared self-efficacy of 129 school counselors serving across all grade levels and did not find a statistically significant difference between those with and without teaching experience. In contrast, Bodenhorn and Skaggs (2005) found that respondents with teaching experience (n = 183) reported significantly stronger self-efficacy than those without teaching experience (n = 42). These conflicting findings about the importance of prior teaching experience suggest that further study is warranted.
Purpose for the Study
Given the importance of beginning career exploration early and the essential role school counselors play in that process, this study focused on career counseling in the middle school setting. Understanding practicing school counselors’ self-efficacy and their time spent providing career counseling will help administrators and policymakers better understand ways to increase career counseling in middle schools. As such, the following research questions were posed: (1) What are middle school counselors’ levels of self-efficacy in career counseling? (2) How does middle school counselor self-efficacy in career counseling vary with previous K–12 teaching experience? and (3) What is the relationship between middle school counselor self-efficacy in career counseling and the amount of time spent providing career counseling?
Method
A quantitative research design was used for this study. The researcher examined school counselor self-efficacy in the career counseling domain. A school counselor was invited to participate if he or she was a current middle school (sixth, seventh, or eighth grade) counselor in Virginia at the time of the study and his or her email information was provided on a district or school website. The electronic survey included three instruments: an information questionnaire that was used to collect data about personal experiences and training, the Career Counseling Self-Efficacy Scale-Modified (CCSES-Modified; O’Brien et al., 1997), and a subscale of the School Counselor Self-Efficacy Scale (SCSE-Subscale; Bodenhorn & Skaggs, 2005).
Descriptive statistics were compiled by computing means, standard deviations, and minimum and maximum scores for total career counseling self-efficacy, as identified by both the CCSES-Modified and the SCSE-Subscale independently. Means and standard deviations of the 25 items of the CCSES-Modified and the seven items of the SCSE-Subscale also were calculated.
Two analyses of variance (ANOVA) and a t-test were used to determine if there were statistically significant differences among means. Participants were given the opportunity to report their years of counseling experience both full- and part-time, and the researcher combined these to get a total number. This number was obtained by taking the total reported number of years as a full-time school counselor and adding that to .5 multiplied by the reported number of years as a part-time school counselor. Then, the researcher created discrete levels to represent groups of experience once the data had been collected in order to conduct the analysis. Identifying the range of experience of the sample and using a scale appropriate for the sample determined the discrete levels. These three levels represented those who had the least experience, those in the middle, and those with the most experience as a school counselor. The researcher conducted an ANOVA with these groups and the SCSE-Subscale mean and a separate ANOVA with the identified groups and the CCSES-Modified mean.
The researcher obtained an answer of “yes” or “no” to indicate previous teaching experience. A separate value was given to answers of “yes” and “no” and the values were used to run a t-test with the mean for the SCSE-Subscale and the CCSES-Modified mean.
Participants indicated the total number of hours of conference presentations, workshops, or trainings that focused primarily on career counseling within the last 3 years. First, the researcher identified the range of the number of hours of training participants reported receiving in career counseling within the last 3 years. Then, the researcher created discrete levels to represent groups of recent training once the data was collected in order to conduct the analysis.
The third research question required a correlation to analyze the relationship between school counselor self-efficacy in career counseling and the amount of time (measured in percent) spent providing career counseling.
Participants
The participants for this study were practicing middle school counselors, defined as counselors working in a school housing students in grades 6 through 8 at the time the survey was completed. The data cleaning procedures described below resulted in 143 participants out of 567 invitations, which is a 25% response rate. Of the 143 participants, 23 (16.1%) were male and 117 (81.8%) were female (three participants omitted this item). Regarding race, 110 participants (76.9%) identified as White/Caucasian, 20 (14.0%) as African American, four (2.8%) as Hispanic/Latino, and one (0.7%) as Multiracial, while five (3.5%) preferred not to answer and three participants omitted this item. Participants’ ages ranged from 25 to over 65 years with an average age of 45 years (SD = 11; respondents who reported being 65 and over were coded as 65).
Regarding training, the participants reported their highest level of education: 125 participants (87.4%) reported having a master’s degree as their highest level of education, 11 (7.7%) had an education specialist degree, six (4.2%) reported having a doctoral degree, and one participant omitted this item. Participants reported a mean of 13.3 years (SD = 7.4) of experience providing school counseling. Regarding full-time teaching experience in a K–12 school, 47 (32.9%) participants had experience, while 94 (65.7%) did not have this experience, and two people omitted this item.
Instruments
The 49-item online survey included 17 items to gather demographic and professional information, the 25-item CCSES-Modified (O’Brien et al., 1997), and seven items from the Career and Academic Development subscale of the SCSE (Bodenhorn & Skaggs, 2005).
Career Counseling Self-Efficacy Scale-Modified. The CCSES-Modified (O’Brien et al., 1997) was used to assess overall career counseling self-efficacy. Participants were asked to indicate their level of confidence in their ability to provide career counseling. For this study, the terms “client” and “career client” were replaced with the term “student” to be more congruent with school counselor terminology. Permission was granted from the first author of the scale to the researcher to make these changes (K. O’Brien, personal communication, January 7, 2013). The CCSES-Modified contains 25 items that are rated on a 5-point Likert-type scale (0 = Not Confident, 4 = Highly Confident). Within the CCSES-Modified, there are four subscales: Therapeutic Process and Alliance Skills, Vocational Assessment and Interpretation Skills, Multicultural Competency Skills, and Current Trends in the
World of Work, Ethics, and Career Research. The full scale has a reported internal consistency reliability coefficient of .96 (O’Brien et al., 1997).
School Counselor Self-Efficacy Scale-Subscale. One subscale from the SCSE (Bodenhorn & Skaggs, 2005) was included in this study. The SCSE Career and Academic Development subscale was designed for school counselors to examine self-efficacy in the career domain. Using a 5-point Likert-type scale (1 = Not Confident, 5 = Highly Confident), participants indicated their level of confidence on each of the seven items. Bodenhorn and Skaggs (2005) reported a subscale internal consistency reliability coefficient of .85.
Indices of Reliability in the Present Study
The internal consistency reliability in this sample for the CCSES-Modified was α = 0.941 and the SCSE-Subscale was α = 0.871. The CCSES-Modified had four subscales: Therapeutic Process and Alliance Skills (10 items, α = 0.820), Vocational Assessment and Interpretation skills (6 items, α = 0.855), Multicultural Competency Skills (6 items, α = 0.913), and Current Trends in the World of Work, Ethics, and Career Research (3 items, α = 0.747). All of these exceed the common threshold for reliability for similar measures. The CCSES-Modified total score and the SCSE-Subscale score had a strong positive 2-tailed Pearson correlation (0.792), which was statistically significant at the 0.01 level. This strong positive relationship suggests these two measures captured related information from the participants.
Procedure
The original sampling frame consisted of 576 middle school counselors with publicly available email addresses, which were collected from public school websites in all counties in Virginia. After Institutional Review Board approval was secured, participants were sent an email invitation with the informed consent and link to the web survey. One week later, participants were sent a reminder email. Upon completion of the survey, participants were given the opportunity to vote for one of five organizations to receive a $100 donation as a token of appreciation for their time completing the survey. After the recruitment email was sent, there were nine people who indicated they were not eligible to participate. These included three individuals who sent a return email indicating that they were out of the office during the survey administration, three who were not currently middle school counselors, two who reported needing school division approval, and one person who had difficulty accessing the survey. This reduced the actual sampling frame to 567.
Data Cleaning
One hundred and sixty-one respondents answered the survey items. There were 18 respondents who omitted 15% or more of the items from the CCSES-Modified or the SCSE-Subscale and were therefore removed from the study. This changed the total number of remaining respondents to 143. Of the 143 remaining, there were eight respondents who each omitted one item that was used to measure career counseling self-efficacy on the CCSES-Modified or the SCSE-Subscale. Each omitted item was replaced with the individual’s scale mean (e.g., mean imputation; Montiel-Overall, 2006), and those respondents were included in the analyses. When the omitted item was part of an analysis for Research Question 2 or 3, the respondent was removed from the affected analysis. Omissions on the demographic questionnaire are noted above in the description of the participants.
Results
RQ1: What are school counselors’ levels of self-efficacy in career counseling?
Overall, middle school counselors who participated in this study were moderately confident, confident, or highly confident in their ability to provide career counseling services. According to the CCSES-Modified, counselors felt least confident in the subscales of Multicultural Competency Skills and Current Trends in the World of Work, Ethics, and Career Research, while they reported the most confidence in their Therapeutic Process and Alliance Skills. Specific areas of school counselor self-efficacy deficits were related to special issues present for lesbian, gay, and bisexual students in the workplace and in career decision-making, as well as special issues related to gender and ethnicity in the workplace and in career decision-making. Table 1 provides descriptive statistics and reliability for each subscale and the total scale.
| Table 1 Career Counseling Self-Efficacy Scale-Modified Subscale Scores (N = 143) |
| Subscales |
Min
|
Max
|
M
|
SD
|
α
|
Item M
|
Item SD
|
| Therapeutic Process andAlliance Skills(10 items) |
21
|
40
|
35.24
|
4.05
|
0.82
|
3.52
|
0.40
|
| Vocational Assessment andInterpretation Skills(6 items) |
5
|
24
|
18.08
|
4.21
|
0.86
|
3.01
|
0.70
|
| Multicultural Competency Skills(6 items) |
0
|
24
|
16.52
|
4.79
|
0.91
|
2.75
|
0.80
|
| Current Trends in the World of Work,Ethics, and Career Research(3 items) |
3
|
12
|
8.09
|
2.44
|
0.75
|
2.69
|
0.81
|
| Total ScaleTotal Instrument Score (25 items) |
32
|
99
|
77.94
|
13.60
|
0.94
|
3.12
|
0.54
|
Note. 1 = Not Confident and 4 = Highly Confident.
The means and standard deviations for the SCSE-Subscale are listed in Table 2. On average, participants were confident or highly confident in their abilities to attend to student career and academic development.
| Table 2 |
| School Counselor Self-Efficacy Scale-Subscale Individual Item Responses (N = 143) |
|
% Response
|
|
1
|
2
|
3
|
4
|
5
|
M
|
SD
|
1. Implement a program which enables all students to make
informed career decisions. |
1
|
3
|
20
|
34
|
43
|
4.16
|
.89
|
2. Deliver age-appropriate programs through which students
acquire the skills needed to investigate the world of work. |
—
|
2
|
18
|
34
|
46
|
4.24
|
.81
|
3. Foster understanding of the relationship between learning
and work. |
—
|
0
|
9
|
40
|
51
|
4.42
|
.65
|
4. Teach students to apply problem-solving skills toward
their academic, personal, and career success. |
—
|
1
|
8
|
36
|
55
|
4.45
|
.69
|
5. Teach students how to apply time and task management
skills. |
—
|
2
|
6
|
35
|
57
|
4.46
|
.71
|
6. Offer appropriate explanations to students, parents, and
teachers of how learning styles affect school performance. |
—
|
2
|
15
|
39
|
44
|
4.24
|
.79
|
7. Use technology designed to support student successes and
progress through the educational system. |
—
|
6
|
22
|
44
|
29
|
3.96
|
.86
|
| Total Subscale Score |
|
|
|
|
|
29.93
|
4.08
|
|
|
|
|
|
|
|
|
|
Note. 1 = Not Confident, 3 = Moderately Confident, 5 = Highly Confident.
RQ2: How does school counselor self-efficacy in career counseling vary with previous K–12 teaching experience?
Two t-tests were conducted to identify if there was a difference between career counseling self-efficacy among participants with and without previous experience as a teacher. Separate means and standard deviations were calculated for the two groups—those who had teaching experience (n = 47) scored higher on the CCSES-Modified (M = 82.2, SD = 9.7) and the SCSE-Subscale (M = 30.9, SD = 3.4) than those without teaching experience (n = 94), CCSES-Modified (M = 75.8, SD = 14.7) and SCSE-Subscale (M = 29.4, SD = 4.3).
Independent t-tests were performed to determine if the differences between the groups were statistically significant. For the CCSES-Modified, the assumption of homogeneous variances was not satisfied (Levene’s test, F = 7.13, p < .05); therefore, the more conservative t-test was used to assess for a statistically significant difference (t = -3.06, p = .003). The mean score for the teaching experience group (M = 82.2, SD = 9.7) was statistically higher than the mean score for those without teaching experience (M = 75.8, SD = 14.7). For the SCSE-Subscale, the assumption of homogeneous variances was satisfied (Levene’s test, F = 3.71, p = .055, d = .51). The mean score of the group with teaching experience (M = 30.9, SD = 3.4, d = .39) was statistically different from the mean score of the group without teaching experience (M = 29.4, SD = 4.3), t = -2.03, p = .045. Cohen’s d is a valuable index of effect size for statistically significant mean differences (Cohen, 1988). The Cohen’s d of .51 for the CCSES-Modified and .39 for SCSE-Subscale both represent medium effect sizes.
RQ3: What is the relationship between middle school counselor self-efficacy in career counseling and the amount of time spent providing career counseling?
The third research question required a correlation to analyze the relationship between school counselor self-efficacy in career counseling and the percent of work time spent providing career counseling. Participants reported the percentage of time they spend providing responsive services to students in the three school counseling domains, as well as testing coordination and other non-counseling–related activities, which is represented in Table 3. The averages and standard deviations of the percentage of time spent in each subscale were: personal/social counseling (M = 36.25, SD = 15.39), academic counseling (M = 23.32, SD = 10.47), career counseling (M = 12.15, SD = 6.98), Virginia State Standards of Learning (SOL) testing coordination (M = 11.83, SD = 12.88), and other non-counseling–related activities (M = 16.44, SD = 12.55). One participant omitted this item; therefore, N = 142 in Table 3. There was no statistically significant relationship between the CCSES-Modified and time providing career counseling (r = .160, p = .057) and a statistically significant weak positive relationship (r = .286, p = .001) between the SCSE-Subscale and time providing career counseling.
| Table 3 Self-Efficacy and Time Providing Career Counseling |
|
% Career Counseling
|
| Career Counseling Self-Efficacy Scale-Modified |
Pearson Correlation |
.160
|
| Sig. (2-tailed) |
.057
|
| N |
142
|
| School Counselor Self-Efficacy Scale-Subscale |
Pearson Correlation |
.286*
|
| Sig. (2-tailed) |
.001
|
| N |
142
|
Note. *Correlation is significant at the 0.01 level (2-tailed)
Discussion
There were several key findings from this study of middle school counselors’ self-efficacy with career counseling. First, it is important to note that there was a wide range in the total self-efficacy scores for middle school counselors. As a group, these counselors were the most confident in their Therapeutic Process and Alliance Skills, and least confident in Multicultural Competency Skills and Current Trends in the World of Work, Ethics, and Career Research. Specifically, special issues related to gender, ethnicity, and sexual orientation in career decision-making and in the workplace were areas of concern. School counselors who had previous K–12 teaching experience were significantly more confident providing career counseling than those without, as assessed by both measures. Finally, a Pearson correlation indicated there was a weak positive correlation between the SCSE-Subscale and the percentage of time school counselors indicated they spend providing career counseling. There was not a statistically significant relationship between the CCSES-Modified and time spent providing career counseling.
In this study, results indicate that middle school counselors spend more time doing non-counseling–related activities than providing career counseling, which is alarming. Career development is one of the three primary domains of a comprehensive school counseling program, and it is important for school counselors to create career development opportunities for students. The majority of school counselors report the importance of career counseling; however, middle school counselors acknowledge they spend less time on career counseling than they prefer (Osborn & Baggerly, 2004). There is a need to reprioritize career counseling, which includes recognizing and acknowledging how career counseling intersects with academic and personal and social counseling in K–12 schools (Anctil et al., 2012).
Career counseling is valuable and evidence needs to be provided to indicate how non-counseling–related tasks take time away from school counselors’ ability to offer adequate career counseling for students. Test coordination is time-consuming and an example of a non-counseling duty that some school counselors perform. Considering the amount of time this role requires, school counselors would find more time to provide career counseling services for students without this obligation. School counselors should gather evidence and provide accountability reports about how career counseling efforts contribute to student engagement and success.
Implications for School Counselors, K–12 Stakeholders, and Counselor Educators
In general, the practicing school counselors in this study had ample self-efficacy with regard to providing career counseling. However, there were certain items on the CCSES-Modified and the SCSE-Subscale that reveal discrepancies in middle school counselors’ levels of confidence. Counselors felt least confident in the subscales of Multicultural Competency Skills and Current Trends in the World of Work, Ethics, and Career Research. Specifically, they reported lower self-efficacy addressing special issues related to gender, ethnicity, and sexual orientation in relation to the world of work. In light of these findings, counselor preparation programs need to further investigate what is being taught in career counseling courses, how the content is being delivered, possible gaps in curriculum, and opportunities for outreach to current school counselors through continuing education. Given the powerful movement for advocacy related to these important social issues, it is in some ways confirming that the practicing counselors in this study felt less confident in these areas. Perhaps the national attention on issues of privilege and oppression related to gender, ethnicity, and sexual orientation has shed light on individual or systemic challenges these school counselors face as they try to serve diverse young adolescents in a dynamic phase of their development.
There are opportunities to increase career counseling self-efficacy related to gender, ethnicity, and sexual orientation in relation to the world of work. Bandura (1997) highlighted personal performance, vicarious learning, and social persuasion as particularly effective strategies for increasing self-efficacy. Continuing education, supervision, and professional organization engagement may be the best opportunities for continued development in these areas (Tang et al., 2004). In-service training and continuing education could be offered to provide school counselors relevant information to support their professional development and promote an increase in career counseling self-efficacy. Gaining up-to-date knowledge about the experiences of students with varied gender identities, ethnicities, and sexual orientations will best prepare school counselors to serve the entire student body. Observing advocacy approaches modeled by other leaders may inspire school counselors to use their voices in their own systems. Relatedly, this finding makes it apparent that K–12 school systems need clear and powerful policies and leadership around gender-, ethnicity-, and sexual orientation-related issues. School counselors are well positioned to partner with principals and superintendents in this important change process.
The second research question provided additional information about a somewhat contentious issue in previous research. School counselors who had teaching experience had higher career counseling self-efficacy than those who did not have teaching experience. This finding contradicts the findings of a study conducted with school counselors in Ohio (Scoles, 2011) and supports the findings of the national study conducted by Bodenhorn and Skaggs (2005), as described above. Contradictory findings like these beg for more research. Perhaps the higher self-efficacy of those with previous teaching experience is related to the preparation in specific academic disciplines that teachers receive. It could be that because these school counselors were previously trained in a specific academic area, they are more confident in talking with students about careers in that particular career cluster (e.g., science teachers who become school counselors may be more prepared to discuss careers in science, technology, engineering, and mathematics with students). Conversely, this potentially narrow view of career opportunities may limit the career exploration of students if school counselors do not include a wide array of career options. An excellent area for further research would be to identify how previous teaching experience may specifically impact school counselor self-efficacy.
School counselors without teaching experience, although lower in self-efficacy than those school counselors with teaching experience, still had high career counseling self-efficacy. This suggests that school counselors without teaching experience have confidence in their ability to provide career counseling. If, as Peterson and Deuschle (2006) suspected, the advantage of those with prior teaching experience is because of the increased training and practice in classroom management and lesson preparation, one would expect that effect to diminish as years of school counseling experience are accumulated. A larger sample than the one in this study would be necessary to test that empirically. If, however, the impetus for the significant impact of teaching experience is more general, those newer school counselors without teaching experience may be adjusting to the setting and to new ways of managing their time, balancing multiple roles and responsibilities, incorporating community involvement, working with parents, fostering collaborative relationships, and becoming familiar with local resources. All of these tasks take time and effort and could impact a school counselor’s self-efficacy to provide adequate services to students. It may be helpful for school counselors without teaching experience to ask for support and suggestions from seasoned school counselors in the district to learn from their experiences. In addition, professional development programming could be established for school counselors to become more familiar with the specific roles and responsibilities related to the career information, education, and counseling needs within a particular community.
Finally, the third focus of the study was on how school counselors use their time and if self-efficacy is related to that allocation. Most alarming about these findings was that school counselors are spending less time providing career counseling than they are doing non-counseling–related duties. A large percentage of middle school counselors’ time was reported to be spent coordinating testing or doing other non-counseling–related tasks, which is not the most efficient use of school counselors’ strengths. School counselors are uniquely trained to provide supplemental support for students in the academic, personal and social, and career domains in order to promote student success; therefore, it would be advantageous if they were able to utilize their time in a way that is consistent with the needs of students. One option to address the time constraint, particularly in this day of tighter budgets, is to utilize someone with an administrative background for the non-counseling duties in order for the school counselor to have time to incorporate adequate career counseling into their school counseling program. This is particularly important for middle school counselors providing career counseling because middle school students are preparing academic and career plans that will serve as a guide through high school and postsecondary educational endeavors (Trusty, Niles, & Carney, 2005; Wimberly & Noeth, 2005).
The world of work is continually changing, which makes it important to be aware of the current trends in this area. As these changes happen, marginalized populations face unique issues in the area of career exploration and planning. Counselors need to be trained adequately to provide career counseling to clients. In addition to providing relevant information, promoting thoughtful reflection, and facilitating discussions for counselors-in-training, counselor educators could provide outreach and continuing education opportunities focused on career counseling.
Just as career counseling may be infused with academic and personal and social counseling for school counselors, counselor educators may consider infusing career counseling concepts throughout other courses and experiences during a training program. Counselor educators could model this authentic type of integration. Counselor educators could talk more about various career clusters and the value of career counseling throughout a training program rather than just in one specific course. Counselor educators may also facilitate discussions with counselors-in-training about their own career counseling experiences, allowing trainees time to reflect on their experience. In addition, trainees could talk about how they have worked with people in roles other than a counselor through the career exploration and planning process.
Counselors need to consider ways to utilize and increase the support of administration and teachers to identify what needs to change in order for them to reallocate their time so they are able to provide more career counseling. Providing evidence of the positive impact of their work may be an effective strategy. There are many approaches to this, such as utilizing current research studies to communicate support for the value of career counseling efforts. In addition, school counselors can gather data from current students, parents, and alumni regarding their perception of and desire for career counseling services through surveys or focus groups. Once specific programs are implemented, school counselors can evaluate the outcomes of the career counseling efforts through both formal and informal assessment procedures with students, teachers, and parents. Administrators should continue to express support for the career counseling efforts of school counselors and show support by advocating for more personnel in order for students to receive adequate career counseling and to meet the demand of the non-counseling tasks that counselors are assigned.
Limitations
The findings should be considered in light of the limitations of the study. Because of the nature of instruments that involve self-report, the results are based on the current perception of the participants and not objective assessments of the effectiveness of their work. Also, it may be more socially and professionally desirable to have confidence in personal abilities and, therefore, some participants may have answered the way they thought they should. This study was limited to those middle school counselors who had publically available e-mail addresses and were working in Virginia. Non-respondents and middle school counselors outside of Virginia are not represented in these findings; therefore, generalizing the findings should be considered with caution. Furthermore, the 406 non-respondents and the 18 respondents who did not complete the entire survey may be systematically different from the 143 respondents who were included.
Conclusion
This study has provided important new information about the self-efficacy of school counselors in the middle school setting as related to career counseling. Career counseling self-efficacy was high overall, with specific areas of deficit related to gender, ethnicity, and sexual orientation. Those school counselors who had previous teaching experience had even higher career counseling self-efficacy than those who did not. High self-efficacy in school counselors had little or no impact on the time spent providing career counseling services. Tailoring continuing education opportunities in career counseling and providing clear administrative leadership would further strengthen practicing school counselor self-efficacy. Utilizing support personnel for non-counseling–related duties may allow school counselors to use their career counseling skills and training to help middle school students explore and connect with careers, thereby improving academic and life outcomes.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Carrie Sanders is a visiting assistant professor at Virginia Tech. Laura E. Welfare, NCC, is an associate professor at Virginia Tech. Steve Culver is Director of Assessment and Analytics at North Carolina A&T State University. Correspondence may be addressed to Carrie Sanders, 1750 Kraft Drive, Suite 2005, Blacksburg, VA 24061, cbrill@vt.edu.
Jul 11, 2017 | Volume 7 - Issue 3
Toni O. Davis, Keith A. Cates
Specialty courts, such as mental health courts, drug courts, and veterans treatment courts, were developed with the intention of reducing recidivism and obtaining better outcomes for participants selected from the particular populations served by each court. Efforts to improve the public good have produced a reimagining of the justice system with a focus on therapeutic jurisprudence and restorative justice. Counselors contract with the courts to provide therapeutic services that assist the courts in supplementing the more traditional court functions of punishment, corrections, and public safety. Mental health clinicians can fulfill pivotal roles in these courts as advocates, educators, and clinical technicians. This paper provides an introduction into specialty courts for counselors considering provision of clinical services in these still-developing areas.
Keywords: specialty courts, mental health courts, drug courts, veterans treatment courts, mental health counseling
In 1963, the passage of the Community Mental Health Centers Act (Feldman, 2003) led to the closing of most state psychiatric hospitals and the provision for providing services at the community level. However, the same act had the unintentional result of transferring patients with severe mental illness from psychiatric hospitals into jails and prisons (Farmer et al., 2017; Hnatow, 2015; Shenson, Dubler, & Michaels, 1990; Torrey et al., 2014). More recently, the war on drugs has exacerbated the problem of overcrowding in penal and justice systems ill-equipped to provide therapeutic services for these individuals (Hafemeister & George, 2012; Harvard Law Review, 1998; Torrey, 1997; Walsh & Holt, 1999). This predicament has led to the Cook County jail in Illinois being labeled as the country’s largest mental health institution (Hill, 2016).
In order to facilitate greater efficiency and effectiveness in the justice system for the populations encountered, specialty courts act to counter a system that historically has depersonalized individuals (Kleinfeld, 2016). Specialty courts identify common issues faced by particular populations and address the underlying causes of criminogenic behavior by focusing on the individual to produce better outcomes. Although mental health professionals fulfill pivotal roles in these courts, many counselors are unfamiliar with specialty courts. The purpose of this paper is to describe the specialty court movement and the roles of counselors within it.
The Justice System—Old and New
The justice system in America has traditionally been one of punitive action—to punish offenders and deter the tempted. Since the 1950s, America’s policies targeting illicit drug use have resulted in a large population of low-level offenders serving long, mandatory-minimum sentences, often with inadequate support and resulting in repeated contact with the traditional criminal justice system (Haley, 2016; Kupers, 2015).
Between 1968 and 1978, the number of patients in state mental hospitals fell 64%, while the census in state prisons rose 65% (Steadman, Monahan, Duffee, & Hartstone, 1984). In 2012, the number of prisoners diagnosed with mental illness exceeded 352,000, more than 10 times the number in state psychiatric hospitals (Torrey et al., 2014). In the absence of evidence that incarceration without treatment is in their own best interest, or that of society (Isaac & Armat, 1990; Kondrat, Rowe, & Sosinski, 2012), such prisoners are a burden on the limited resources of prison systems in every state.
The specialty court movement arose to address the specific needs of the mentally ill, drug offenders, and other populations, and to effect a decrease in the underlying causes of criminal behavior and thereby reduce the number of people incarcerated in jails and prisons. Specialty courts take the traditionally adversarial roles of prosecution and defense and turn them into cooperative roles to foster a therapeutic environment for those individuals who would benefit (Kondo, 2001). Veterans treatment courts are a more recent addition to the specialty court movement, joining mental health courts, drug courts, gun courts, domestic violence courts, and other specialized courts (Baldwin, 2016). Veterans treatment courts treat underlying causes of crime and other challenges faced by veterans and service members.
The Center for Court Innovation developed three organizing principles for specialty courts (Boldt, 2014). The first principle is a problem-solving orientation that identifies and addresses underlying causes of criminality common to specific groups; the second principle is cooperation with community resources offering treatment and oversight; and the third principle is accountability (Boldt, 2014). These principles work within the context of the two major approaches of specialty courts: therapeutic jurisprudence and restorative justice.
Two Working Approaches in Specialty Courts
The specialty court movement is based on two overarching approaches: therapeutic jurisprudence, which seeks improved outcomes for the individual facing charges; and restorative justice, which seeks restitution for all stakeholders.
Therapeutic jurisprudence promotes a wellness paradigm using the court as a therapeutic tool. Therapeutic jurisprudence takes the approach that it is in the best interest of society to work cooperatively with all stakeholders to provide better outcomes in criminal justice. The model is a new paradigm based on a cooperative and non-adversarial approach of judges, prosecutors, defense attorneys, and community and mental health professionals (Haley, 2016).
Restorative justice is the idea that justice is served by restoration, both to the individuals and to the community affected by crime. In traditional court settings, restoration includes financial restitution by the offender (to the victims) in addition to incarceration (for the public good). The Centre for Justice & Reconciliation has defined restorative justice as a process to heal harms and bring about transformation for all parties (Centre for Justice & Reconciliation, 2017). This is necessary because crime is more than simply breaking the law. Crime also causes people harm and hurts relationships and the community. Thus, a just response needs to address the harms as well as the wrongdoing (Centre for Justice & Reconciliation, 2017). Restorative justice in specialty courts focuses on treatment options for an individual’s issues, which promotes the restoration of the offender. Working with specialty courts allows mental health counselors to combine individual therapy with vocational counseling, oversight of community service for program participants, aftercare supervision, and mediation and arbitration with victims to emphasize accountability for the individual (Haley, 2016), impacting the restorative process for all stakeholders. Integrating the counselor’s toolbox with all of these challenges requires skill and patience.
Clinical Integration With Specialty Courts
Specialty courts are challenging for all stakeholders. Judges must transition from performing as adjudicators of justice to facilitators of treatment, and the clinician serves both the court and the program participants by providing treatment services. Counselors educate and advocate for participants and are able to frame program objectives into long-term treatment outcomes and participant prognoses for judges and court officers (Kupers, 2015). The mental health counselor, as a therapeutic service provider, becomes a de facto expert who the court relies on to assist in the development and implementation of treatment goals (Hughes & Peak, 2012).
Specialty courts are full of legal terminology, and counselors working with the court can assist in conveying meaning clearly to program participants. A better-informed client will be more able to give informed consent and have more buy-in to the process. Facilitating education for participants increases the likelihood of successful completion of the program, which in turn translates to an improved quality of life and reduction in re-arrest rates (Haley, 2016).
Participants in specialty courts will bring many issues to treatment. Counselors may provide assessments for the presence of mental health disorders, substance use, and social service needs, and they may be called upon to facilitate other assessments on an as-needed basis.
Jurisdiction for participants is an area with a large amount of variety from program to program. For individuals that may be eligible for different programs, placing their case under the jurisdiction of one specialty court over another becomes a question of resources. For example, some mental health courts are able to address the substance use issues of participants, while others are not (Fisler, 2015).
Specialty courts operate under the model of managed care, in which the treatment modalities are brief and evidence-based, such as with cognitive behavioral therapy (Kupers, 2015). The Council of State Governments outlined best practices for the creation of mental health courts (Thompson, Osher, & Tomasini-Joshi, 2007), which included behavioral modification techniques and operant conditioning as a key educational element, and included instruction on proper use of negative and positive reinforcement techniques (Russell, 2015). Judges and court officers are able to use the Council of State Governments’ model to structure their courts within the limitations of local resources and needs. Awareness of these needs and limitations allows the clinician to be more effective in influencing outcomes and program success for participants of specialty courts, of which three types are included in this discussion: drug courts, veterans treatment courts, and mental health courts.
Drug Courts
In 1989, a judge in Miami, Florida, started ordering drug users that came before the court into treatment in lieu of jail. Out of this was born the drug court, which has now become the model for specialty courts. The Miami court started as a response to the criminogenic life-cycle experienced by low-level offenders appearing before the court: substance use → crime → jail → release, then repeat (Fulkerson, 2009). The effect of the new paradigm on the cycle became: substance use → crime → treatment → support and supervision, leading to reduced recidivism (Haley, 2016). Since that time, drug courts have quickly spread across the nation. By 2001, there were more than 700 drug courts in the United States (Harrison & Scarpitti, 2002) and 1,600 as of 2010 (Haley, 2016).
Drug courts use supervision and monitoring to ensure compliance to program requirements. Counselors serve as agents of the court, verifying adherence through substance abuse treatment services, drug testing, talk therapy, and encouraging abstinence as a condition to successful completion. Counselors working with drug court participants face a rather straightforward challenge, in which compliance to program requirements and overall program success can be quantified through drug testing and analysis of available data, including re-arrest rates. More complicated are issues facing participants in other specialty courts, such as the veterans treatment courts.
Veterans Treatment Courts
As of 2010, the United States had deployed approximately 1.9 million service members to serve in Afghanistan and Iraq (Rizzo et al., 2011). Conflicts from the Middle East have left the United States with over 40,000 wounded (Rizzo et al., 2011) and over 350,000 service members with traumatic brain injury (Baldwin, 2016). As the United States continues to conduct military operations around the world, the need exists to address the specific concerns of veterans returning to non-combat duties. Veterans treatment courts (VTCs) are now addressing, via the drug court model, various needs of this population (Slattery, Dugger, Lamb, & Williams, 2013). The first VTC was established in 2004 in Anchorage, Alaska, but the model from which most programs are built is the one established in Buffalo, New York, in 2007–2008 (Baldwin, 2016).
Issues the counselor may face with participants in VTCs include post-traumatic stress disorder, substance use, military sexual trauma, major depression, and neuropsychological problems (Eisen et al., 2012), as well as homelessness and unemployment issues (Baldwin, 2016). In addition to services available to participants in other specialty courts, VTCs are designed and built recognizing differing needs of supervision and support, including cooperation with the Veterans Administration (VA) and other service members (Russell, 2015). Connections the VTCs have through the VA make a difference for participants, who rely heavily on the VA for benefits. VA connections cannot easily be replaced or replicated and are scarce in many locales (Clark, McGuire, & Blue-Howells, 2014).
VTCs also differ from many other specialty courts in that they have a peer-mentoring component. Mentoring is the use of previous program participants and other service members in a peer-support role, similar to their use in 12-step programs as part of a successful drug treatment protocol. Mentoring is more important for this population because of the military’s highly structured culture and the importance of respect for others with military experience (Clark et al., 2014; Russell, 2015).
Like other specialty courts, VTCs have some variance in those eligible for participation. VTCs often limit participation to those with certain mental health diagnoses or substance abuse issues and to those who are not charged with a felony or violent crime. Eligibility also may be restricted to only those deployed to a combat zone or only those who are eligible for VA benefits.
Funding for VTCs is different than that of other specialty courts, which rely on local sources of funding. VTCs get most of their funding through the VA (Russell, 2015), which operates through strict guidelines. In fact, VA guidelines currently limit the role of counselors, preferring instead services performed by psychiatrists and psychologists—a slightly different perspective than one seen in mental health courts.
Mental Health Courts
The first mental health court was introduced in the late 1990s in Broward County, Florida (Linhorst et al., 2009), and by 2010 there were over 200 operating in the United States (Fisler, 2015; Hughes & Peak, 2012). Individuals enter the court system through arrest, usually for minor offenses (Hnatow, 2015; Walsh & Holt, 1999). Mental health courts differ from drug courts in the wider variety of conditions that must be addressed and the greater degree of treatment individualization available for participants. More robust measurement of program success is required as well. In drug court, success can be measured by length of time spent in sobriety. In mental health court, the variety of illnesses and conditions specific to the individual requires more advanced assessment and occurs in the arena of a team approach, with counselor, case manager, psychologist, and court administration involved in the process.
Again, there is variance in the design and operation of mental health courts. The Council of State Governments’ document begins with the assumption that mental health courts are designed with the cooperation of a variety of individual stakeholders, all of whom may bring a wide range of goals with them (Fisler, 2015). The focus on public safety and court jurisdiction means eligibility criteria is again an issue. Most programs exclude individuals facing charges for felonies and violent crimes (Linhorst et al., 2009).
Counselors working with mental health courts have great influence on participant eligibility, as well as treatment options. Counselors work to inform participants of the risks of participation, potential benefits, their rights and responsibilities, requirements of successful program completion, and any ramifications of program failure. Again, counselors who are able to communicate clearly with participants can develop the rapport needed for buy-in and informed consent. With specialty court familiarity, counselors can address concerns and considerations.
Clinical Concerns and Considerations
Confidentiality and Privacy
Kupers (2015) advocated for the need to keep interventions confidential and private. Specialty court participants’ hearings before a judge should be segregated from regular court proceedings and entered in the specialty court docket (the list of cases to be tried). This may mean that all participants be placed on dockets in a separate courtroom and, if possible, in separate locations. Public mingling with individuals awaiting their turn on the docket represents an all-too-real possibility of the loss of confidentiality and privacy.
Up-front disclosure of the limits of confidentiality will lead to a participant more able to give informed consent, a deeper rapport with clients, and greater diligence on the part of the counselor (Kupers, 2015). In an era of multidisciplinary teams, confidentiality requirements must be rigorous. As with regular notes, counselors’ and case managers’ personal notes need segregation from formal notes used in treatment. Case managers should keep specific treatment information separate from court files, and if an individual fails the program or withdraws, transfer documents used by the court should be created using general treatment information to ensure confidentiality (Linhorst et al., 2009).
Consistency of Programs
Consistency is an issue surrounding all areas of specialty court programs. One concern lies within law enforcement. The primary point of contact between an individual with mental illness and the justice system is often police or the county sheriff (Walsh & Holt, 1999). Having the ability to divert a person during daily operations, law enforcement benefits the most from training to identify and work with the mentally ill. In their survey of Virginia sheriffs, Walsh and Holt (1999) found that the majority of sheriffs received little or no instruction on working with individuals with mental illness.
More available training serves the public by providing more capable officers. Officers with experience and training in the diverse expression of mental illness and substance use are better able to recognize an individual in need or in crisis, with better outcomes (Ogloff et al., 2012). Overall, officers trained to deal more appropriately with detainees can reduce inappropriate incarceration, use of emergency services, recidivism, and cost to communities (Hnatow, 2015).
Consistency is necessary for fair and uniform needs assessments. Proper assessment is a cooperative process, requiring diligent coordination between counselors, case managers, and court officers. Regular meetings with stakeholders will promote assessment service needs, availability of services and costs, location and acquisition of funding, and specification of outcomes and outcome measurements (Walsh & Holt, 1999). With training and assessment addressed, counselors can direct more energy to advocacy needs.
Advocacy
Counselors have a duty to educate and advocate for the communities with which they interact and the American Counseling Association (2003) is fully in support of this ideal. On the surface, this may appear to be in opposition to the demands of working in the arena of specialty courts, but counselors are in an ideal situation to promote better outcomes for clients through advocacy efforts (Grob, 1995; Kupers, 2015).
By providing services to participants and advocating for programs, counselors working with specialty courts not only actively serve client needs, but also provide ethical and pragmatic examples of conduct for those considering service to these populations. Linhorst et al. (2009) also noted that counselor participation contributes to the development of best practices for the courts.
Conclusion
Specialty courts represent a new frontier for counselors. As mental health experts, counselors are the key to successful outcomes for participants (Linhorst et al., 2009). The need for cooperation and coordination by stakeholders with opposing goals and objectives and the increased scrutiny of treatment are challenges that await counselors with the courage to work with participant populations within specialty courts. The rewards of seeing change and improvement in participants’ lives far outweigh the concerns of operating in these still-developing areas.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Toni O. Davis is a graduate student at Troy University. Keith A. Cates, NCC, is an associate professor at Troy University. Correspondence can be addressed to Toni Davis, #368 Hawkins Hall, Troy University, Troy, AL 36082, badaxe824@yahoo.com.
Jun 18, 2017 | Volume 7 - Issue 3
Jessica Z. Taylor, Susan Kashubeck-West
This study examined preferences for counseling topics to discuss in individual, group, and family counseling among young adults with cancer, as well as their ranked preferences for attending individual, group, and family counseling. A sample of 320 young adults with cancer (18–39 years old) completed an online survey containing items relevant to young adults’ psychosocial needs. Participants rated anxiety, finances, sad feelings, sexual and intimacy concerns, and stress management as most helpful for individual counseling; finding social support and getting information about one’s medical situation as most helpful for group counseling; and no topics as most helpful for family counseling. Participants rated individual counseling as their primary choice of counseling modality, followed by group counseling, and lastly family counseling. Counselors may help young adult clients by familiarizing themselves with the unique experience of being diagnosed with cancer at an early age, as well as providing age-specific in-person support and counseling group opportunities.
Keywords: cancer, young adult, counseling preferences, counseling modality, psychosocial needs
The leading disease-related cause of death for adolescents and young adults is cancer, with almost 70,000 individuals newly diagnosed each year (Nass et al., 2015). Adolescents and young adults with cancer have specific psychosocial needs that are not the same as those of adults with cancer, yet we know comparatively little about those needs. In 2006, the National Cancer Institute called for research on the specific psychosocial needs of adolescents and young adults diagnosed with cancer. In 2013, an Institute of Medicine workshop reviewed the progress made since 2006 and reported that many challenges remained (Nass et al., 2015). Zebrack (2011) stated that developing age-appropriate support services would benefit adolescents’ and young adults’ psychosocial well-being. For young adults with cancer, having a counselor that is knowledgeable about their unique psychosocial needs is especially important (Katz, 2015). Psychosocial needs and concerns related to quality of life may include relationships with others, emotions, body image, and spirituality (Sodergren et al., 2017). Indeed, young adults with cancer experience psychosocial and supportive care needs that are “not only unique to their age group but also broader in scope and more intense than those at any other time in life” (Bleyer & Barr, 2009, p. 204). These individuals need to be a priority for counseling researchers, and we should be attuned to young adults’ particular psychosocial needs and desires for counseling to help them as much as possible (Kumar & Schapira, 2013). Therefore, this study was designed to examine the perceived counseling needs of young adults with cancer.
We focused on individuals aged 18–39 because they have been shown to be developmentally different from adolescents (e.g., Arnett, 2000) and because they often have been lumped in with adolescents in research on their mental health needs (Haase & Phillips, 2004; National Cancer Institute, 2006). Although there are some similarities between adolescents and young adults with cancer in terms of psychosocial needs (Husson et al., 2017; Nass et al., 2015; Sender & Zabokrtsky, 2015; Sodergren et al., 2017), a growing discussion emphasizes the importance of exploring psychosocial needs across developmental age groups within the adolescent and young adult age range. This discussion especially focuses on the need for developing appropriate counseling and other psychosocial services (Fasciano, Souza, Braun, & Trevino, 2015; Iannarino, Scott, & Shaunfield, 2017; Katz, 2014, 2015; Salsman et al., 2014; Smith et al., 2013).
Generally, literature addressing the mental health needs and service usage of individuals with cancer is more abundant for older adults and for young adult survivors of childhood cancer, rather than for young adults diagnosed with cancer between the ages of 18 and 39 (Rabin, Simpson, Morrow, & Pinto, 2011). The research on the mental health needs of and service usage by adult cancer survivors older than 40 years of age suggests that they have a lower desire for, and utilization of, counseling services than do young adults with cancer (Gadalla, 2007; Hewitt & Rowland, 2002; Mosher et al., 2014). This need is largely unmet in the young adult population, in part because they may encounter difficulties affording counseling services (Hewitt & Rowland, 2002) or locating counseling services designed specifically for young adults with cancer (Marris, Morgan, & Stark, 2011; Zebrack, 2009).
Furthermore, there has been little research on the topics young adults with cancer would find beneficial to discuss in counseling or on the counseling modalities in which young adults with cancer would like to discuss specific topics. The current study’s authors previously conducted the first-known study (Taylor & Kashubeck-West, 2013) to ask young adults with cancer to rate the helpfulness of specific topics of discussion across different counseling modalities (i.e., individual, group, and family counseling). A sample of 151 young adults with cancer rated 11 items as helpful to discuss in individual counseling: (a) stress management and/or anxiety; (b) putting your own needs before others’ needs; (c) negative self-talk and sad feelings; (d) positive thinking; (e) living day to day; (f) trying to live a “normal” life; (g) finances; (h) partner concerns; (i) sexual and intimacy concerns; (j) finding social support; and (k) concerns with family. Participants identified the topic of trying to live a “normal” life as the most helpful individual counseling topic and alcohol or drug use as the least helpful topic of discussion. Within-group differences were found in that emerging adults (i.e., between the ages of 18–29 [Arnett, 2000]) rated the topic regarding thoughts about continuing or resuming education as significantly more helpful to discuss in individual counseling than did young adults (i.e., between the ages of 30–39 [Arnett, 2000]). Young adults rated the topic regarding partner concerns as significantly more helpful to discuss in individual counseling than did emerging adults. These findings seem to reflect age-related developmental tasks.
Taylor and Kashubeck-West (2013) also found that when asked to rate helpful topics for group counseling, young adults with cancer rated six topics on a group counseling needs assessment as helpful to discuss in group counseling with other young adults with cancer: (a) talking about feelings; (b) sharing medical information; (c) finding different ways to think about and cope with the experience; (d) finding meaning and purpose from the experience; (e) discussing concerns about intimate relationships; and (f) discussing concerns about casual relationships. These findings are consistent with Zebrack, Bleyer, Albritton, Medearis, and Tang (2006), who found that young adults with cancer ranked the opportunity to meet other young adults with cancer as being one of their top supportive care needs, regardless of whether young adults with cancer were currently receiving or had completed medical treatment.
Young adults with cancer may attempt to protect the feelings of family members and others by not wanting to discuss their diagnosis or negative feelings about it (Hilton, Emslie, Hunt, Chapple, & Ziebland, 2009; MacCormack et al., 2001), suggesting a hesitancy to fully utilize family counseling. When Taylor and Kashubeck-West (2013) asked participants to rate how helpful 19 different topics would be to discuss in family counseling, only two topics were rated as being helpful: stress management and accepting the new “normal.” Not only did young adults with cancer rate the fewest items as helpful to discuss in family counseling, dating concerns—a relational topic—was identified as the topic young adults with cancer least wanted to discuss in family counseling. Developmentally, as young adults with cancer work to gain independence from their family (Arnett, 2000), they may not see family counseling as an appealing option for supportive care.
The purpose of this study was to further examine the preferences of young adults with cancer for counseling topics and counseling modalities. This study builds on the 2013 study by Taylor and Kashubeck-West by using a larger sample of young adults with cancer, recruiting from a greater number of sources, and including more psychosocial concerns relevant to young adults with cancer using a counseling needs assessment tool. In extending previous exploratory work on this topic, this descriptive study had two primary goals: (a) to gain greater clarity of young adults’ preferences for topics to discuss in individual, group, and family counseling; and (b) to understand young adults’ preferences for these three counseling modalities. The results of this study provide counselors with helpful information as they attempt to meet the counseling needs of young adults with cancer.
Method
Participants
Participants were 320 young adults with cancer currently between the ages of 18 and 39, initially diagnosed with cancer at age 18 or older, and living in the United States. Descriptive analyses (see Table 1) showed that a majority of the sample identified as female (86%), Caucasian/White (87%), and heterosexual (94%). The mean age of the sample was 31.17 years old (range 18–39 years; SD = 5.14). A majority of participants were partnered or in a committed relationship (68%), 71% had obtained at least an undergraduate degree, and 66% were currently employed, with approximately 17% unemployed and 17% on medical or disability leave. Participants in the sample reported living in 41 states and Washington, D.C.
Approximately half of the participants (51%) reported that they had received counseling from a mental health professional (e.g., counselor, social worker, psychologist, psychiatrist, pastor, or priest) since their initial cancer diagnosis. A majority of participants (66%) had tried to find a local in-person support group for young adults initially diagnosed with cancer during young adulthood, but less than half (48%) were successful in finding a local group.
On average, participants in the current sample were initially diagnosed with cancer at 27.76 years old (range 18–38 years; SD = 5.34). Participants reported 26 different initial cancer diagnoses, with seven diagnoses being reported more frequently: (a) Breast (29%), (b) Brain (16%), (c) Hodgkin’s Lymphoma (10%), (d) Thyroid (10%), (e) Leukemia (8%), (f) Non-Hodgkin’s Lymphoma (7%), and (g) Testicular (5%). A majority of participants (70%) reported they had completed medical treatment; 29% were currently receiving medical treatment. Of participants who had completed medical treatment, the mean number of months since completing treatment was 32.68 (range 0–192; SD = 36.31).
Most participants (78%) reported no recurrence of cancer. Of those who did have a recurrence (n = 69), the mean age at recurrence was 30.00 years old (range 19–38 years; SD = 5.44) and the mean duration of time between initial cancer diagnosis and recurrence was 2.06 years (range 0–10 years; SD = 1.88).
Procedure
All study procedures were approved by the university Institutional Review Board. Participants were recruited from cancer organizations based in the United States relevant to young adults with
Table 1
Characteristics of Study Participants (N = 320)
Gender
Male 45 (14.1)
Female 275 (85.9)
Race/Ethnicityb
Caucasian/White 279 (87.2)
African American/Black 10 (3.1)
Asian American 11 (3.4)
Hispanic/Latina(o) 28 (8.8)
Native American 3 (0.9)
Other 5 (1.6)
Current Socioeconomic Status
Lower Class/Working Class 52 (16.3)
Lower Middle Class 73 (22.9)
Middle Class 148 (46.4)
Upper Middle Class 42 (13.2)
Upper Class 4 (1.3)
Sexual Orientation
Heterosexual 297 (94.3)
Bisexual 12 (3.8)
Gay/Lesbian 6 (1.9)
Highest Level of Education
Did Not Complete High School 1 (0.3)
Completed High School/GED 13 (4.1)
Some College 77 (24.1)
Obtained Undergraduate Degree 122 (38.2)
Some Graduate School 31 (9.7)
Obtained Master’s Degree 63 (19.7)
Obtained a Doctorate 12 (3.8)
Stage/Grade of Initial Cancer Diagnosis
0 23 (7.5)
1 75 (24.5)
2 108 (35.3)
3 70 (22.9)
4 30 (9.8)
Note. a Totals do not equal 320 because of missing data. b Percentages greater than 100% because of participants being able to select from more than one category. cancer and with an online social media presence. Organizations were asked to post a recruitment solicitation for this study on the organization’s Facebook and Twitter social media websites. In addition to a convenience sample, snowball sampling was used. The recruitment postings invited potential participants to send the study information to other young adults with cancer. Professional contacts with access to young adults with cancer (e.g., cancer support organization program directors, cancer-related non-profit executive directors, and academic professionals with expertise in psychosocial issues experienced by individuals with cancer) also were asked to invite young adults with cancer to participate. Upon completion, participants were invited to participate in a raffle separate from the study survey for one of 20 randomly chosen $10 gift certificates to Amazon.com. Counseling needs assessment items were presented in random order within counseling modality to prevent systematic order effects; similarly, counseling modality was presented randomly.
Measures
Counseling needs assessment. Based on a review of the literature and feedback from two young adults with cancer, Taylor and Kashubeck-West (2013) developed three counseling needs assessment tools to explore topics that young adults with cancer might find helpful to discuss in individual, group, and family counseling. Their individual counseling needs assessment contained 31 items (Cronbach alpha = .91), their group counseling needs assessment contained 6 items (Cronbach alpha = .80), and their family counseling needs assessment contained 19 items (Cronbach alpha = .86). Comparisons of topic helpfulness between counseling modalities was limited because of the needs assessments containing different items.
The current study revised Taylor and Kashubeck-West’s (2013) counseling needs assessments into one counseling needs assessment that was used to explore topic helpfulness for each counseling modality to better allow for topic comparisons. Reviewing the literature, soliciting feedback from psychosocial oncology mental health and nursing experts, and consulting with young adults with cancer led to the revised 38-item counseling needs assessment used in the current study. Participants were asked to rate their perception of how helpful each of 38 topics would be to discuss in individual counseling, group counseling, and family counseling. Individual counseling was defined as “attending counseling by yourself” (Cronbach alpha = .96); group counseling was defined as “attending counseling with people you have never met before who also have been diagnosed with cancer between the ages of 18–39 and are currently between the ages of 18–39” (Cronbach alpha = .97); and family counseling was defined as “attending counseling with someone you personally know” (Cronbach alpha = .98). Participants selected their responses on a Likert-based scale ranging from 1 (very unhelpful) to 3 (neither helpful nor unhelpful) to 5 (very helpful) for each of the three counseling modalities. Finally, participants were asked to rank their preferences for counseling modalities, with 1 being their most preferred counseling modality and 3 being their least preferred.
Demographic items. Participants were asked to report their age, gender, race/ethnicity, relationship status, sexual orientation, and current socioeconomic status. Additionally, they were asked about their medical treatment status—whether they were currently in medical treatment for their cancer diagnosis or if they had completed medical treatment—as well as how many months it had been since they completed medical treatment, if applicable. Participants were asked if they had received counseling since their initial cancer diagnosis and whether they had tried to find a local, in-person support group specifically for young adults with cancer. If they had tried to locate a local in-person young adults with cancer group, participants were asked if they had been successful in finding one.
Results
The first goal of this study was to explore the perceived helpfulness of topics for young adults with cancer to discuss in individual counseling, group counseling, and family counseling. A mean helpfulness rating of 3.50 or greater on a 1 to 5 Likert-based scale—on which 3.0 was neither helpful nor unhelpful—was selected as indicating that a topic was rated as helpful to discuss in counseling. Individual counseling and group counseling both had 25 topics rated as helpful, and family counseling had 12 topics rated as helpful. Thus, participants found more than twice as many topics helpful for discussion in individual and group counseling compared to family counseling. See Table 2 for average helpfulness ratings by topic across the three counseling modalities.
Table 2
Mean Differences Between Counseling Topics Across Counseling Modalities and ANOVA Results
Individual Group Family
Variable M (SD) M (SD) M (SD) N F h2 Power
1. Accepting the new “normal”a 4.15a (.99) 4.22a (.96) 3.86b (1.14) 286 21.76*** .07 1.00
2. Alcohol or drug use 2.65a (1.34) 2.70a (1.29) 2.49b (1.21) 287 5.98** .02 .88
3. Anxietya 4.19a (.99) 4.03b (1.06) 3.77c (1.18) 283 26.39*** .09 1.00
4. Being accepted by others 3.55a (1.14) 3.63a (1.17) 3.26b (1.16) 282 17.30*** .06 1.00
5. Concerns with child(ren)a 3.30a (1.33) 3.30a (1.33) 3.22a (1.41) 280 .92 <.01 .21
6. Concerns with family members 3.45a (1.21) 3.37a (1.22) 3.37a (1.26) 283 .79 <.01 .19
other than partner, parent(s),
sibling(s), or child(ren)
7. Concerns with friend(s) 3.68a (1.07) 3.69a (1.07) 3.35b (1.16) 283 17.50*** .06 1.00
8. Concerns with parent(s)a 3.57a (1.18) 3.50ab (1.22) 3.39b (1.22) 285 3.83* .01 .69
9. Concerns with partner 3.67a (1.21) 3.53ab (1.25) 3.43b (1.28) 288 6.27** .02 .90
10. Concerns with sibling(s) 3.33a (1.22) 3.21a (1.26) 3.24a (1.22) 285 2.04 .01 .42
11. Creating a memorable 3.28a (1.23) 3.29a (1.23) 3.18a (1.27) 285 1.92 .01 .39
document of your life
for yourselfa
12. Creating a memorable 3.34a (1.23) 3.32a (1.21) 3.25a (1.27) 286 1.00 <.01 .22
document of your life to share
with loved onesa
13. Dating concernsa 3.11a (1.43) 3.15a (1.44) 2.65b (1.33) 284 28.97*** .09 1.00
14. Finances 3.82a (1.13) 3.65b (1.21) 3.60b (1.25) 285 6.10** .02 .89
15. Finding meaning in lifea 3.61a (1.18) 3.57a (1.17) 3.35b (1.19) 283 10.35*** .04 .99
16. Finding purpose in life 3.60a (1.15) 3.59a (1.17) 3.33b (1.17) 284 12.36*** .04 1.00
17. Finding social support 3.84a (1.08) 4.05b (.99) 3.58c (1.19) 282 24.59*** .08 1.00
18. Finding/making meaning 3.70a (1.10) 3.73a (1.13) 3.48b (1.21) 281 8.91*** .03 .97
from your diagnosisa
19. Getting information about 3.52a (1.17) 3.77b (1.13) 3.51a (1.23) 288 10.55*** .04 .99
your medical situation
20. How and what to tell your 3.16a (1.37) 3.27a (1.31) 3.18a (1.39) 282 2.18 .01 .45
child(ren) about your situation
21. Infertility issues 3.55a (1.35) 3.50a (1.35) 3.17b (1.44) 286 19.01*** .06 1.00
22. Insurance issues 3.63a (1.20) 3.56ab (1.25) 3.40b (1.29) 288 6.09** .02 .89
23. Job situation 3.70a (1.20) 3.55a (1.22) 3.29b (1.24) 286 18.39*** .06 1.00
24. Living day to day 3.78a (1.13) 3.85a (1.13) 3.62b (1.16) 285 6.50** .02 .91
25. Making memories for your 3.37a (1.20) 3.35a (1.24) 3.33a (1.34) 284 .17 <.01 .08
child(ren)/partner/family to have
26. Negative self-talk 3.68a (1.24) 3.68a (1.15) 3.36b (1.20) 283 15.46*** .05 1.00
27. Pacing yourself to prevent
exhaustiona 3.74a (1.14) 3.80a (1.11) 3.52b (1.20) 287 12.27*** .04 1.00
28. Pain and its effect on your life 3.66a (1.11) 3.71a (1.15) 3.47b (1.23) 285 8.82*** .03 .97
29. Positive thinkinga 3.99a (1.03) 3.97a (1.02) 3.72b (1.10) 286 12.88*** .04 1.00
30. Putting your own needs 3.86a (.99) 3.79a (1.02) 3.55b (1.14) 287 15.38*** .05 1.00
before others’ needs
31. Sad feelingsa 4.08a (1.01) 3.85b (1.08) 3.62c (1.19) 288 27.90*** .09 1.00
32. Sexual/intimacy concernsa 3.87a (1.10) 3.44b (1.31) 3.31b (1.38) 286 26.93*** .09 1.00
33. Spiritualitya 3.25a (1.23) 3.25a (1.27) 3.12a (1.21) 284 2.92 .01 .56
34. Stress managementa 4.22a (.97) 4.09b (1.00) 3.84c (1.15) 288 22.78*** .07 1.00
35. Talking more effectively with 3.74a (1.16) 3.79a (1.11) 3.51b (1.24) 288 10.83*** .04 .99
health care professionals
regarding your physical condition
36. Thoughts about 3.32a (1.20) 3.32a (1.23) 3.09b (1.25) 288 10.36*** .04 .99
continuing/resuming education
37. Trusting the doctora 3.45acd (1.17) 3.55ac (1.15) 3.33bcd (1.20) 286 7.31** .03 .93
38. Will/advanced directive concernsa 3.39a (1.18) 3.26a (1.21) 3.33a (1.19) 287 1.83 .01 .38
Note. Power = observed power at α < .05. Means sharing a common subscript are not statistically different at p < .05 according to Bonferroni pairwise comparison tests.
a Greenhouse-Geisser correction utilized for violation of Mauchly’s Test of Sphericity at p < .05 * p < .05; ** p < .01; *** p < .001
Next, we compared participants’ ratings of counseling topic helpfulness among the three counseling modalities. A two-way within-subjects multivariate analysis of variance (MANOVA) was conducted to assess the interaction effect of counseling topic and counseling modality. There was a significant multivariate interaction effect: Pillai’s V = .59, F(74, 144) = 2.77, p < .001, η2 = .59, observed power = 1.00. Given this significant multivariate interaction effect, a one-way within-subjects analysis of variance (ANOVA) was conducted for each of the 38 counseling topics included on the counseling needs assessment tool to better understand which topics were perceived as more helpful to discuss in certain counseling modalities (see Table 2 for ANOVA results).
Participants rated five topics as significantly more helpful to discuss in individual counseling than in the other two counseling modalities: (a) anxiety, (b) finances, (c) sad feelings, (d) sexual and intimacy concerns, and (e) stress management. The two topics (a) finding social support and (b) getting information about your medical situation were rated as being significantly more helpful to discuss in group counseling versus the other two counseling modalities. Finally, participants rated three topics as significantly more helpful to discuss in individual counseling than in family counseling: (a) concerns with parent(s), (b) concerns with partner, and (c) insurance issues. No topics were rated as significantly more helpful to discuss in family counseling than in individual or group counseling.
The second goal of this study was to examine whether there were differences in young adults’ counseling modality preferences. Frequencies and percentages for counseling modality preferences can be found in Table 3. A majority of participants selected individual counseling as their first choice for counseling modality (73%), followed by group counseling (21%), and, finally, family counseling (7%). For second choice, the highest frequency of participants selected group counseling (45%), followed by family counseling (35%), and lastly, individual counseling (21%). For participants’ third choice, family counseling was selected most frequently (59%), followed by group counseling (35%), and lastly, individual counseling (6%).
Table 3
Counseling Modality Preferences (N = 296)
First Choice
Individual Counseling 215 (72.6)
Group Counseling 61 (20.6)
Family Counseling 20 (6.8)
Second Choice
Individual Counseling 62 (20.9)
Group Counseling 132 (44.6)
Family Counseling 102 (34.5)
Third Choice
Individual Counseling 19 (6.4)
Group Counseling 103 (34.8)
Family Counseling 174 (58.8)
To explore whether significant differences existed among rankings of preferences for counseling modalities, a one-way within-subjects ANOVA was conducted. In conducting the analysis, Mauchly’s Test of Sphericity was statistically significant (W = .93, p <.001), indicating heterogeneity of covariance matrices across levels of preference rankings for counseling modalities (Meyers, Gamst, & Guarino, 2006). Therefore, a Greenhouse-Geisser correction was utilized for interpreting results. The observed F value was statistically significant: F(1.87, 551.48) = 169.30, p < .001, η2 = .37, observed power = 1.00. Bonferroni pairwise comparison tests (p < .05) demonstrated that participants ranked individual counseling (M = 1.34, SD = .59) significantly higher than group counseling (M = 2.14, SD = .73), which in turn received a significantly higher ranking than family counseling (M = 2.52, SD = .62). Thus, participants ranked attending individual counseling as their first preference for counseling modality, followed by group counseling ranked as their second preference, and finally family counseling ranked as their last preference.
Discussion
The purpose of this study was to further examine the perceived counseling needs of young adults with cancer with regard to counseling. A paucity of research has studied counseling topic and modality preferences for young adult clients with cancer in depth. Both individual and group counseling had the same number of topics rated as helpful (25/38 topics), and 15 topics were rated as being equally helpful in group or individual counseling. Many of the 15 topics are discussed in the literature as relevant to young adults with cancer: infertility concerns (Eiser, Penn, Katz, & Barr, 2009; Gupta, Edelstein, Albert-Green, & D’Agostino, 2013; Katz, 2015; Kent et al., 2012), the “new normal” (Miedema, Hamilton, & Easley, 2007; Odo & Potter, 2009; Snöbohm, Friedrichsen, & Heiwe, 2010), employment (Katz, 2015; Odo & Potter, 2009; Zebrack, 2011), and pacing oneself to prevent exhaustion (Hauken, Larsen, & Holsen, 2013; Odo & Potter, 2009; Snöbohm et al., 2010), among other developmentally relevant topics. Participants indicated that discussing anxiety, finances, sad feelings, sexual and intimacy concerns, and stress management in individual counseling would be significantly more helpful than discussing these topics in group counseling or family counseling. Perhaps because these topics are fairly unique to one’s specific life context, they may not be topics that would be as helpful to discuss with other family members or with other young adults with cancer. They may be topics that young adults with cancer prefer to gain insight about on their own, with a counselor providing feedback. Alternatively, they may be topics that are perceived as being too sensitive to discuss with others. Especially in regard to financial concerns or sad feelings, perhaps young adults with cancer do not want to worry or burden friends and family with their concerns (Brennan, 2004; MacCormack et al., 2001).
Participants rated the topics of finding social support and getting information about one’s medical situation as significantly more helpful for discussion in group counseling than in individual or family counseling. Group counseling itself can be a way for young adults with cancer to find social support from others who understand their experiences (Kent et al., 2013). In addition, young adults with cancer may use group counseling to solicit advice and brainstorm ideas of how they can enhance their social support system. Even if someone is from a different background, such as a different social class, that person may be able to provide relevant information for increasing social support and interacting with one’s support system. Similarly, getting information about one’s medical situation is a topic that is not as context-specific as some of the topics rated as helpful to discuss in individual counseling (e.g., finances). Speaking with other young adults with cancer about one’s medical experience and soliciting information about their medical experiences may be beneficial.
Consistent with Taylor and Kashubeck-West’s (2013) findings, family counseling did not have any topics that were rated as more helpful to discuss in family counseling than in the other two counseling modalities. In addition, a few notable instances of family-relevant topics were rated significantly more helpful for discussion in individual counseling than in family counseling. These topics included discussing concerns about one’s parents, concerns about one’s partner, and insurance issues. Although the topics discussing concerns with parents or with a partner may seem best suited for discussion in family or couples counseling, young adults with cancer were significantly more interested in discussing these concerns in individual counseling. Perhaps young adults with cancer do not want to appear ungrateful to others and would prefer to utilize individual counseling as a way to express frustration or as a way to consider alternative ways of interaction. This possibility would be consistent with MacCormack et al.’s (2001) finding that adult cancer survivors tend to prefer discussing concerns regarding family members in individual counseling rather than in family counseling.
This study also explored how young adults with cancer would rank preferences for counseling modality. Descriptive frequencies indicated that a strong majority of participants (73%) chose individual counseling as their first choice of counseling modality over group counseling or family counseling. Examining helpful counseling topics may be beneficial in understanding this result. Topics rated as more helpful to discuss in individual counseling than in other forms of counseling tended to be topics more specific to one’s life context, such as financial concerns. Additionally, the topics involved feelings that may be perceived as negative feelings, such as anxiety, sadness, and stress. Topics chosen as most helpful to discuss in group counseling did not share the same underlying affective nature, but were related more to asking other young adults with cancer for their advice, experiences, and support. Counselors and other professionals should consider young adults’ emotional state and purpose for attending counseling when recommending utilization of individual or group counseling. This study provides evidence that young adults with cancer do not particularly prefer family counseling or feel that discussing many topics in family counseling would be helpful. Developmental tasks during young adulthood, such as gaining independence from one’s family of origin, may contribute to this.
Implications for Counselors
Because participants in this study selected individual counseling as their first choice for counseling modality, counselors need to familiarize themselves with what young adults with cancer may want to discuss in individual counseling, as well as how a young adult may experience a cancer diagnosis during young adulthood. Katz’s (2014, 2015) two books focusing on the psychosocial lived experience of young adults with cancer would be a beneficial starting point for counselors to familiarize themselves with relevant issues. When first exploring the concerns of clients who are young adults with cancer, counselors can begin by examining relevant developmental concerns related to the five counseling topics young adults with cancer in this study rated as being most helpful to discuss in individual counseling. Because the identified helpful topics relate primarily to emotions, an emotion-focused therapeutic approach (Greenberg, 2004) may be beneficial for young adult clients. Taylor, Hutchison, and Cottone (2013) reviewed three existentially based individual counseling models for adult cancer survivors that counselors may consider based on their young adult clients’ needs: (a) dignity therapy, (b) meaning-making intervention, and (c) short-term life review.
An implication of this study for counselors relating to group counseling involves the limited availability of support groups for young adults initially diagnosed with cancer in young adulthood (Kumar & Schapira, 2013). Of the study participants who looked for a young adult cancer support group, less than half were successful in finding one. Young adults may then turn to the Internet to find support, but even then they may not be successful in locating the type of support they need (Cohen, 2011). More local support groups for young adults diagnosed with cancer during young adulthood are needed to provide them with a uniquely powerful experience in which they are heard and understood by others like them, rather than by others much younger or older. Additionally, local counseling groups for young adults with cancer diagnosed during young adulthood that are led by counselors who understand their psychosocial concerns are needed. Taylor et al. (2013) reviewed four existentially based group counseling models for adult cancer survivors that counselors may consider based on their young adult clients’ needs: (a) cognitive-existential group therapy, (b) self-transcendence group therapy (c) meaning-centered group psychotherapy, and (d) supportive-expressive group therapy.
Participants’ lack of interest in the family counseling modality is an interesting result of this study. This result is supported by MacCormack et al.’s (2001) finding that many adults with cancer try to protect their friends and families by not sharing all of their emotional experiences with them. Rather than make general recommendations for clients who are young adults with cancer to participate in family counseling, counselors may want to make such recommendations on an individualized basis after thoroughly exploring clients’ psychosocial needs and preferences. Young adults with cancer are in a developmental period in which they are striving to live as independent adults (Arnett, 2000). A counselor suggesting that a young adult client with cancer participate in family counseling may be perceived as a suggestion that the client is unsuccessfully navigating this developmental period. For young adults who are interested in family counseling, a biopsychosocial approach guided by a medical family therapy framework (McDaniel, Hepworth, & Doherty, 1992) may be worth considering. This study can aid counselors in formulating hypotheses for what young adults with cancer may perceive as beneficial in different counseling modalities, as well as what types of counseling these clients would find helpful.
Implications for Future Research
Utilizing qualitative research methods may be especially helpful for future researchers (Kent et al., 2012) in continuing to explore young adults’ preferences for counseling topics in different counseling modalities. Researchers could incorporate the counseling topics included in this study in their interview questions to further explore these psychosocial areas, as well as to discover additional helpful counseling topics. Inquiring about the results of the counseling modality preferences in a qualitative study also could lead to further understanding about the contexts behind selecting one modality over another.
Additionally, research exploring how counseling can increase quality of life for young adults with cancer would be a significant contribution to the literature. Quinn, Gonçalves, Sehovic, Bowman, and Reed’s (2015) systematic review of the literature revealed a dearth of evidence-based approaches to enhance quality of life for adolescents and young adults with cancer. Because an experimental or quasi-experimental research design would be necessary to interpret whether counseling leads to an increase in quality of life, conducting such a research study would be complex and costly. But, a research study following up on these results to examine whether discussion of certain topics, participation in different counseling modalities, or particular counseling models can increase quality of life for young adults with cancer would greatly benefit the development of evidence-based psychosocial services for young adults with cancer.
Limitations
Mono-method bias was an inherent limitation to this study because of the sole use of self-report for data collection. Additional limitations include the use of a convenience sample, as well as lack of diversity among the participant characteristics of gender and race. Furthermore, the possibility exists that there are other counseling topics that young adults with cancer would find helpful to discuss in counseling that were not included on this study’s counseling needs assessment tool. Finally, if participants had never experienced one or more of the included counseling modalities, they may have been unsure about their perception of how helpful topics would be to discuss in those modalities or how they would rate their modality preferences.
Conclusion
The purpose of this study was to examine the perceived counseling needs of young adults with cancer. This study resulted in clarifying topics young adults with cancer would find helpful to discuss in individual counseling, group counseling, and family counseling. Young adults rated anxiety, finances, sad feelings, sexual and intimacy concerns, and stress management as most helpful for individual counseling; finding social support and getting information about one’s medical situation as most helpful for group counseling; and no topics as most helpful for family counseling. This study also found that young adults with cancer ranked individual counseling as their first choice for counseling modality, followed by group counseling and family counseling. Counselors and other mental health professionals can use these results as starting points for therapeutic conversations in various counseling modalities, creating treatment plans, establishing in-person groups, and developing evidence-based psychosocial programming and services for young adults with cancer in a variety of medical and supportive care settings.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Jessica Z. Taylor is an assistant professor at Central Methodist University. Susan Kashubeck-West is a professor and Associate Dean for Research at the University of Missouri–St. Louis. The authors would like to thank Hope for Young Adults with Cancer and the College of Education at the University of Missouri–St. Louis for their contributions of incentives for randomly selected study participants.Correspondence can be addressed to Jessica Taylor, Central Methodist University, 2458 Old Dorsett Road, Suite 200, Maryland Heights, MO 63043, jztaylor@centralmethodist.edu.
May 26, 2017 | Volume 7 - Issue 2
Yvette Saliba, Sejal Barden
Occupational stress is a top source of stress for over 65% of Americans due to extended hours in the workplace. Recent changes in health care have encouraged employers to build workplace wellness programs to improve physical and mental health for employees to mitigate the effects of occupational stress. Wellness programs focus on either disease management; treating chronic illnesses, such as hypertension and diabetes; lifestyle management; or preventing chronic illnesses through health promotion. This manuscript provides an overview of recent changes in health care and describes a conceptual framework, Steps to Better Health (S2BH), that counselors can use in workplace wellness programs. S2BH is an 8-week psychoeducational group based on the combination of motivational interviewing (MI) and the transtheoretical model of change (TTM).
Keywords: wellness, health care, workplace, stress, Steps to Better Health
Health and wellness are two concepts that have captured the attention of people throughout history. From Greek mythology to modern times, the idea of well-being has permeated society (Myers & Sweeney, 2007). Today, with the Patient Protection and Affordable Care Act (PPACA), health care is moving away from a disease treatment model and embracing a disease prevention model (PPACA, 2010). Although individuals typically do not invest in preventive health measures, many businesses and companies are eager to improve their health care programs for employees (Willis Towers Watson, 2017). These changes in health care are relevant to mental health providers, as a new focus on prevention has created opportunities for counselors to help effect lasting health changes among employees. Therefore, to fit into this paradigm shift, professional counseling should be strongly connected to prevention and wellness (Granello, 2013). This article discusses the changes in health care models, how those changes are creating spaces for mental health counselors to fill and implications for the counseling profession.
The Changing Landscape of Health Care
In 2015, the Kaiser Family Foundation released a report highlighting the rising cost of health care expenditures from 1960 to 2013. This report indicated that health care costs, which include total costs for hospital visits, physicians and clinics, as well as prescription medications, have risen from 27.4 billion dollars to over $2 trillion (Kaiser Family Foundation, 2015). Due in part to increases in the cost of health care and health insurance, the PPACA was passed into federal law in 2010. Mandates of the PPACA include: (a) preventing the denial of coverage for pre-existing conditions; (b) strengthening community health centers; (c) decreasing health disparities; (d) promoting integrated health systems; (e) connecting physician payments to the quality rather than the quantity of care provided; and (f) lowering long-term costs by providing free and more comprehensive preventive care (U.S. Department of Health and Human Services, Health Care, 2016). In a White House memo sent out during National Public Health Week in 2014, President Obama stated, “my administration is supporting efforts across our country to improve public health and shift the focus from sickness and disease to wellness and prevention” (Obama, 2014, p. 1).
This shift is clearly seen in the PPACA. Section 4001 of the PPACA, entitled “Modernizing Disease Prevention and Public Health Systems,” discusses ways in which health prevention should be carried out within the public sector (PPACA, 2010). This portion of the law includes a taskforce team that would: (a) evaluate wellness programs in 2013; (b) create the Prevention and Public Health Fund to distribute money to worksites establishing wellness programs; (c) further the education of health and wellness promotion; and (d) report on measures enacted that address lifestyle behavior modification (PPACA, 2010). Lifestyle behavior modification is defined as activities that include “smoking cessation, proper nutrition, appropriate exercise, mental health, behavioral health, substance use disorder, and domestic violence screenings” (PPACA, 2010, p. 422). In other words, initiatives from the federal government highlight the emphasis on prevention in both community and clinical health venues and extend this focus by supporting research into workplace wellness initiatives (Anderko et al., 2012). Though the PPACA encourages workplace wellness programs, many employers see the benefits to their employees even without federal regulations. In a recent survey, employers indicated they are still committed to better workplace wellness programs despite the unknown future of the PPACA (Willis Towers Watson, 2017). One primary motivator behind these programs is a reduction of employee stress through health promotion.
Health Promotion in the Workplace
According to the 2015 Bureau of Labor and Statistics report, Americans spent 8.8 hours a day at work or doing work-related activities (U.S. Department of Labor, 2016). Therefore, it can be estimated that Americans spend much of their lives in workplace settings, which can lead to occupation-related stress. In 2012, the American Psychological Association’s (APA) Stress in America Survey revealed that 65% of Americans reported work as a top source of stress (APA, 2016). Stress can affect a person’s emotional state, and it also can weaken the body’s ability to regulate itself after a stressful experience, which can eventually cause detrimental health consequences (Galla, O’Reilly, Kitil, Smalley, & Black, 2015). For example, the effects of chronic stress have been shown to lead to obesity and metabolic diseases (Razzoli & Bartolomucci, 2016). As a result, many individuals have resorted to maladaptive ways of coping with stress, highlighting the need for bringing stress management skills to the workplace (Galla et al., 2015). In addition, the World Health Organization has stated that health promotion in the workplace (promoting aspects of physical and emotional wellness) is beneficial in combating work-related stress (Jarman, Martin, Venn, Otahal, & Sanderson, 2015).
Finding ways to help employees manage their stress through health promotion in the workplace is typically conducted through workplace wellness programs, which include both lifestyle and disease management programs (Caloyeras, Hangsheng, Exum, Broderick, & Mattke, 2014; Kaspin, Gorman, & Miller, 2013; Mattke et al., 2013). Promoting positive health habits among employees maintains affordable health coverage and increases worker productivity (Anderko et al., 2012; Parkinson, Peele, Keyser, Liu, & Doyle, 2014; Shapiro & Moseley, 2013). Most workplace wellness programs focus on disease management, treating chronic illnesses such as diabetes and hypertension. Disease management programs also typically utilize health care professionals, such as nurses, to conduct face-to-face meetings or telephone consultations (Caloyeras et al., 2014). Conversely, lifestyle management programs prevent chronic illnesses by: (a) reducing stress; (b) lowering weight; (c) encouraging exercise; (d) promoting smoking cessation; and (e) fostering overall well-being (Caloyeras et al., 2014; Kaspin et al., 2013; Mattke et al., 2013).
Wellness Programs
Johnson & Johnson was an early pioneer in the creation and promotion of workplace wellness programs. In the 1970s, the company implemented a wellness program for employees called Live for Life (Ozminkowski et al., 2002). In 1993, this program was modified to integrate the following additional services: (a) employee health; (b) occupational medicine; (c) health promotion; (d) disability management; and (e) an employee assistance program. A modified program was rebranded with a new title: The Johnson & Johnson Health & Wellness Program (Ozminkowski et al., 2002). At the time of the program analysis, Johnson & Johnson employed approximately 40,000 people in the United States, 90% of whom participated in their wellness program. The program was evaluated by comparing outpatient doctor visits, hospital inpatient stays and mental health visits over the course of four years as compared to three years prior to the start of the wellness program. The worksite wellness program resulted in significant annual savings per employee/per year. On average, the study reported $45.17 savings for each outpatient visit, $119.67 per inpatient stays and $70.69 for mental health visits. In sum, Johnson & Johnson reported over $8 million in annual savings (Kaspin et al., 2013; Ozminkowski et al., 2002), creating a model wellness program that has been replicated in other organizations to varying degrees.
In contrast, PepsiCo offered a program in 2004 that did not produce similar results. Over 55,000 employees participated in a 3-year study, and it was determined that while costs were high in the initial year, it was the disease management portion of the program that lowered overall medical expenses by the third year (Liu et al., 2013). The disease management program was six to nine months in length and involved regular phone calls with a nurse for 15 to 25 minutes (Caloyeras et al., 2014). The program focused primarily on conditions such as asthma, coronary artery disease, congestive heart failure, hypertension and strokes (Caloyeras et al., 2014). Conversely, the lifestyle management portion of the program, which focused on weight management, nutrition management, fitness, stress management and smoking cessation, was described simply as involving a “series of telephonic calls with a wellness coach over a six-month period” (Caloyeras et al., 2014, p. 125). Training to become a wellness coach varies widely, ranging from a few days to 6 months. Training typically requires an associate degree and 18 weeks of classes conducted over the telephone or four full days of training in topics that include: (a) growth-promoting relationships; (b) expressing compassion; and (c) eliciting motivation to overcome ambivalence (Wellcoaches, 2016). The lack of sustainable changes in lifestyle wellness programs may be due to the variation and brevity of training for wellness coaches.
Hospitals have started employee wellness programs to lower employee health insurance costs, support mental health, and recruit and retain quality employees (Caloyeras et al., 2014; Hochart & Lang, 2011; Liu et al., 2013; Parkinson et al., 2014). Ironically, while the health care system is designed to help patients achieve good health, it often comes at the price of high stress levels and poor health for the employees (Chang, Hancock, Johnson, Daly, & Jackson, 2005; McClafferty & Brown, 2014; Smith, 2014). In fact, hospital employees tend to exhibit poorer health than other types of employees, which results in hospitals having the highest health care costs among employment sectors in the United States (Parkinson et al., 2014). As a result, some hospitals, such as the University of Pittsburgh Medical Center, are introducing the idea of employee wellness programs. In 2005, the University of Pittsburgh Medical Center utilized a prepackaged wellness program called MyHealth—a program that included both lifestyle and disease management components (Parkinson et al., 2014). Based on the number of requirements an employee met and activities he or she engaged in, the program provided credit that could be used to lower insurance deductibles (Parkinson et al., 2014). MyHealth consisted of online education materials, self-help tools, telephonic health coaching and support groups for lifestyle issues such as smoking cessation, depression, and emotional health and stress issues (Parkinson et al., 2014). Over a 5-year period, overall health care costs were lowered, but again, savings were attributed to the disease management portion of the program and not the lifestyle management portion (Caloyeras et al., 2014). Although there has been moderate success with wellness programs, the inclusion of counselors could make these programs more successful.
Need for Counselors in Wellness Programs
Changes in health care and increases in worksite wellness programs have created footholds for trained mental health professionals. As evidenced in the cases above, health care professionals, rather than mental health professionals, are facilitating lifestyle wellness programs. This is unfortunate, as professional counselors are trained in the skills of rapport building, demonstrating empathy and helping others achieve their goals. To build upon counselors’ inherent training and strengths may reduce the need for additional support and behavior change training. Utilizing counselors may result in stronger program implementation and cost savings for companies (Groeneveld, Proper, Absalah, van der Beek, and van Mechelen, 2011). Furthermore, although there have been some promising results and modest savings due to wellness programs, the variability in the content of wellness programs ranges widely. Therefore, it is proposed that having a program designed and led by counselors may have the potential to create larger savings for the lifestyle management portion of worksite wellness programs. With counselors utilizing their skills and coupling these techniques with aspects of motivational interviewing (MI) and the transtheoretical model of change (TTM), they could strengthen the lifestyle management portion of wellness programs and build on the foundation of wellness in counseling. To this end, we propose a psychoeducational lifestyle management conceptual framework that combines both MI and the TTM in an 8-week program, entitled Steps to Better Health (S2BH), which is described in the following section.
Components of S2BH
MI is an approach that helps individuals motivate themselves to pursue the changes that they seek. The founders of MI, Miller and Rollnick (2013), defined MI as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” (p. 12). More precisely, MI is about skillfully arranging conversations so that people talk themselves into changing (Miller & Rollnick, 2013). Further, MI has been positively correlated with stress reduction, medication adherence, diet change and exercise participation (Rollnick, Miller, & Butler, 2008). Miller and Rollnick (2013) asserted that people from all backgrounds could be trained to use the tools of MI; however, they emphasize that MI is not simply a collection of techniques (Miller & Rollnick, 2013). Rather, MI should be applied in a context that is characterized by client-counselor collaboration, client independence, and empowering clients to find and use their own resources for change (Young, Gutierrez, & Hagedorn, 2012). In addition to MI, the proposed wellness program integrates the TTM, an evidence-based model for change, and research on effective group work.
The TTM was developed by Prochaska and DiClemente (1982) to facilitate behavioral changes for individuals (Campbell, Eichhorn, Early, Caraccioli, & Greeley, 2012). The TTM consists of five stages of change individuals experience when changing behavior. The five stages are: (a) pre-contemplative (not thinking about change); (b) contemplative (thinking about change); (c) preparation (taking steps to begin change); (d) action (making the change); and (e) maintenance (creating a habit of new change; Shinitzky & Kub, 2001).
Prochaska et al. (2008) reviewed employee health promotion interventions, and results demonstrated that both MI and the TTM individually can lead to effective change. Participants (N = 1400) at a major medical university were assigned to three treatment groups: brief health risk intervention (BHRI) only (n = 433), online TTM-tailored treatment (n = 504), and an MI treatment group (n = 433; Prochaska et al., 2008). The results of the study showed that both the MI and TTM treatment groups had more individuals participating in the action stage for exercise and indicated better management of stress along with less health risk behaviors in 6 months than the BHRI only group (Prochaska et al., 2008). This study suggests that if both MI and TTM are effective separately, then combining them could lead to further success. Additionally, utilizing this combination within the framework of a psychoeducational group for a workplace would create efficiency.
Psychoeducational group work is ideal for a wellness program as it is a “hybrid of an academic course and counseling session” (Brown, 2011, p. 8). This format allows participants to feel as though they are attending a class, which can help them focus on learning and implementing a specific task without the potential stigma of therapy. For working professionals who may not feel the need to participate in traditional counseling, a psychoeducational group provides opportunity for discussions and activities in which individuals can practice various wellness techniques in a safe setting. Additionally, groups can be more cost-effective for businesses and organizations, as a number of individuals can simultaneously accomplish goals in a shared timeframe.
For many wellness programs, the results have been mixed due to expensive training and inadequate application of behavior change principles. For the lifestyle management portion of these wellness programs to be successful, a stronger framework would need to be implemented along with the use of professionally trained counselors. Therefore, a conceptual framework that counselors can consider adapting for a wellness lifestyle management program is proposed. The intention is to emphasize critical theoretical components while integrating practical ideas for counselors to build upon and adapt into their own lifestyle and health management programs.
S2BH
The proposed intervention of S2BH is an 8-week pyschoeducational group that incorporates aspects of both MI and the TTM. Each session consists of a short lesson about a concept related to change followed by a discussion that progressively moves each participant toward making the decision to change and successfully enacting those changes. Devoting 1 hour per week over the span of 8 weeks would yield overall balance and wellness among employees, leading to higher work performance and lower absenteeism (Vitality Institute, 2014). In addition to group sessions, the counselor should be available for optional one-on-one follow-up sessions, up to two times after the initial 8 weeks, ideally at the employer’s expense. These sessions would provide the opportunity for employees to address specific wellness concerns to help maintain changes. For demonstration purposes, below is a brief case example that demonstrates how S2BH could be utilized. In addition, Table 1 contains an overview of the program.
Case Illustration
Polly, a 46-year-old oncology nurse for 20 years, and Amelia, a 35-year-old oncology nurse for 9 years, work at Metro Hospital, a 2,000-bed acute care medical facility located in a busy downtown area. Both Polly and Amelia were frustrated about their workloads and felt burned out because of job stressors. They were both interested in joining the S2BH group, as it would give them more points in Metro’s HealthyYou! Campaign. These additional points could later be translated into monetary bonuses to encourage employee participation. After gaining permission from their nurse manager to be part of the S2BH group, both women joined seven other nurses from different floors once a week for an hour during their lunch break. Both Polly and Amelia completed physicals as a part of the campaign, and despite weight and blood pressure issues, neither of the physicals for both women showed severe health concerns.
During their first meeting, Polly shared feeling fatigued and believing that her lack of exercise played a part in that. Amelia stated that though she managed to walk once a week, she still felt lethargic both emotionally and physically, but was not sure why. During this first group, the counselor utilized one of the central principles of MI, which reflects listening skills to express empathy and genuine caring for the nurses. To close the group, everyone received the S2BH Wellness Primer Worksheet as homework.
Table 1
Suggested Curriculum for Steps to Better Health
|
Weekly Session
|
Session Details
|
Activities in Session
|
Homework Assigned
|
|
Week 1: Rapport Building and Therapeutic Alliance
|
Counselor will welcome the group and explain the weekly format, with emphasis on goal attainment. |
Participants will be encouraged to share work-related stressors and wellness goals. |
A worksheet will be provided for participants to outline wellness goals, steps needed to achieve goals and identification of stressors. |
|
Week 2:
Wellness Education
|
Participants will explore reasons for change and discuss the homework from the previous session. |
Participants will discuss potential pitfalls and necessary supports for successful change. |
Participants will identify what problems they encountered with their last change attempts. |
|
Week 3:
The Stages of Change
|
Counselor will give lesson on TTM, focusing on the stages of change. |
Participants will identify which stage of change they are in and work to develop stage-matched interventions. |
Participants will write down the advantages and disadvantages of achieving their wellness goal(s). |
|
Week 4:
Exploring Ambivalence
|
Counselor will lead a discussion on ambivalence (Miller & Rollnick, 2013; Shinitzky & Kub, 2001). |
Participants will discuss benefits and costs of not changing behavior. |
Each participant will identify one to two new habits as they move toward their wellness goal(s). |
|
Week 5:
Habit Formation
|
Counselor will discuss how participants can create new habits. |
Using homework, members will identify cues/routines/rewards for each new habit identified (Duhigg, 2012). |
Each participant will bring to the next session a brief update on their wellness goal(s). |
|
Week 6:
Reframing & Risk Assessments
|
Participants will discuss triggers and potential tactics to adhere to personal goals. |
Participants will identify and isolate potential triggers and solutions for the individual. |
Participants will identify stressors from work and life that could jeopardize wellness goal(s). |
|
Week 7:
Stress Busters
|
Participants will discuss stress and ways to enhance coping skills (e.g., emotion-based and action-based). |
Participants will use homework to identify appropriate coping skills for each stressor. |
Participants will use one of the identified coping skills over the next week. |
|
Week 8:
Wrap-Up
|
Participants will discuss how to stay motivated and engaged with wellness plans. |
Participants will discuss achievements followed by a termination activity. |
No homework assigned. |
Polly and Amelia came back to the second group with their S2BH Wellness Primer Worksheet results and were a little hesitant to begin discussing their results. After a few other members shared, Polly stated that the wellness primer made her more aware of her lack of exercise. Amelia then shared that this was the first time she had sat down and reflected on her health and well-being, and though she was not sure it was necessarily helpful, she was willing to try anything to stop feeling “blah.” Following the discussion on the wellness primer, group members worked on developing a wellness plan for the areas they wanted to improve. To close the session, the counselor discussed with the members ways to begin working on their goals in incremental steps and noted different ways they had started addressing those steps.
After learning about the stages of change from the TTM in the third session, Polly was animated about which stage she was on in relation to her goal of exercising more. She shared that she had been stuck on the contemplative stage of change for more years than she could count. She stated that she wanted to lose weight but could not seem to motivate herself to walk before her shift started.
Amelia stated that she wanted to eat better and classified herself as being in the pre-contemplative stage of change. She reported that she needed to eat better because she relied too often on caffeine and sugary foods to keep her going throughout the work day. Several of the group members expressed hope in knowing that they were not just “being lazy,” but were in a process of change. Amelia stated that just knowing that gave her a boost of energy.
After checking in during the fourth session and finding out where everyone was with their goals, the counselor led a discussion on the MI concept of ambivalence. Polly found this a little challenging, as she just wanted to list the pros and cons of her new health goals: exercising and eating better. Once she understood that she was to list both the benefits and costs of continuing her current behavior versus enacting her new health goal, she became more involved in the activity. As a result, Polly listed some pros of walking in the morning as being “it centers me as I release some of the frustration from the day before,” and “I use this time to organize my mind for the upcoming tasks for the day.” Amelia stated that some of her cons for not changing her behavior included “crashing hard around 4 p.m. in the afternoon” and “losing focus when working with patients.”
For the fifth session, a discussion centered around Duhigg’s (2012) book, The Power of Habit: Why We Do What We Do in Life and Business, and how members could apply the principle of cue, reward and routine to help them achieve their goals. Polly stated that she started putting her walking shoes out with her exercise clothes so that she could immediately see them when she woke up (cue). She would play her favorite podcast while walking (routine), and reward herself with a small low-calorie pastry for breakfast (reward). Amelia stated that she started to place almonds and other energy-boosting snacks at the nurses’ station so she could easily see them (cue), then would snack on those items while talking with colleagues (routine). As a result, she felt her energy lasting longer throughout the day (reward).
The nurses enjoyed reframing their previous “relapses” in the sixth session. Amelia reported that she was aware it was normal to move back and forth between the stages and that this knowledge alleviated concerns about failure. The group had a lively discussion about what triggers or pitfalls stood in their way and what places or things they should avoid as a result. For example, Polly stated that if she hit the “snooze button,” she would stay in bed and forgo her walk. Realizing this, she opted to place her alarm clock across the room so that she would have to get out of bed to turn off the alarm.
The seventh session on stressors became more emotional than anticipated as many of the nurses talked about their work and the unique stress they experience when taking care of ill and terminally ill patients. The group members talked about their thoughts and feelings and supported one another during this session. As a result, a spontaneous sharing of how nurses deal with the grief of losing patients occurred. Amelia shared that she had recently decided to join Team in Training for the Leukemia and Lymphoma Society and train for a half marathon in memory of one of her younger patients. She stated that letting the family know and beginning to raise money for research in this area was helping her to positively channel her grief. As a result of this discussion, several of the nurses stated that they left the group with hope, connectivity, and ideas for channeling their grief and stress.
The final session of the group focused on closure. Amelia shared that although she was initially dubious about the group, as a result of her sharing and the small changes she was making with her snacking, she was not feeling as “blah” anymore. Polly also shared that while she had not lost weight yet, she felt more motivated to continue walking and noticed that she felt more positive about walking.
Conclusion
Changes in health care have increased job opportunities in health care for counselors. The PPACA allows counselors the opportunity to expand their background of wellness while capitalizing on preventive health care initiatives (Barden, Conley, & Young, 2015; Granello & Witmer, 2013). With the interrelatedness between physical and mental health, counselors are ideally positioned to help clients achieve their wellness goals. Connections between physical activity and psychological well-being are well established, as are the potential benefits of improved coping with stress and adversity (Focht & Lewis, 2013). Because chronic stress has been shown to contribute to obesity and metabolic diseases (Razzoli & Bartolomucci, 2016), helping employees improve their coping skills can lead to adaptive ways of dealing with stress, which ultimately impacts chronic health conditions. To better manage occupational stress, counselors can fill the need for bringing stress management skills to the workplace (Galla et al., 2015).
In addition, wellness programs provide the ability for counselors to research their contributions to workplace wellness programs, thereby providing an opportunity to study counselor effectiveness. Research has shown that using health care professionals in disease management portions of wellness programs can lower costs. The focus of this manuscript has been to describe a framework for counselors to facilitate lifestyle management programs in corporate settings. Considerable sponsored research opportunities also are available, especially for worksite wellness programs targeted to underserved populations (U.S. Department of Health and Human Services Office of Minority Health, 2016).
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Yvette Saliba, NCC, is a doctoral student at the University of Central Florida. Sejal Barden, NCC, is an Associate Professor at the University of Central Florida. Correspondence can be addressed to Yvette Saliba, 851 South State Road 434, Suite #1070-170, Altamonte Springs, FL 32714, ysaliba@knights.ucf.edu.
