May 2, 2025 | Volume 15 - Issue 2
Alexandra Frank, Amanda C. DeDiego, Isabel C. Farrell, Kirby Jones, Amanda C. Tracy
State policies and school district regulation largely shape the roles and responsibilities of school counselors in the United States. The American School Counselor Association (ASCA) provides guidance on recommendations for school counseling practice; however, state policies may not align with guiding principles. Using a rubric informed by the ASCA National Model, we conducted a problem-driven content analysis to explore state policy alignment with the Define, Manage, Deliver, and Assess components of the model. Our findings indicate state policy differences between K–8 and 9–12 grade levels and within each rubric component. School counselors and school counselor educators can use these findings to support strategic advocacy efforts aimed at increased clarity around school counselors’ roles and responsibilities.
Keywords: content analysis, advocacy, state policy, school counseling, ASCA National Model
What is a school counselor? The profession has a long history of attempting to answer this question, not always successfully. Role confusion in school counseling was highlighted by Murray (1995) who stated that the roles of school counselors often vary from the printed job description. Murray attributed unclear counseling duties to misunderstandings about school counselors’ roles by stakeholders, such as administrators, parents, and students. Murray also found that differences in legislative definitions of school counseling contributed to role confusion. As an early act of advocacy in school counseling, Murray suggested developing a uniform definition of school counseling, advocating for that definition, and engaging in effective communication strategies among stakeholders as solutions to role confusion. Since this early movement to define school counseling roles, professional groups (e.g., The American School Counselor Association [ASCA]), academic organizations (e.g., School Counselors for MTSS), and professional conferences (e.g., The Evidence-Based School Counseling Conference and ASCA conference) have joined in the efforts to describe school counselor identity and roles. Despite these efforts, school counselors across the United States struggle with the lack of clarity in their roles (Bardhoshi & Duncan, 2009; Chandler et al., 2018).
School counselors’ impacts on student outcomes are well-documented (O’Connor, 2018). When describing the role and influence of school counselors, researchers point to improved student outcomes, such as decreased student behavior issues (Reback, 2010), increased student achievement (Carrell & Hoekstra, 2014), and increased college-going behavior (Hurwitz & Howell, 2014). School counselors’ roles in supporting student social–emotional health became particularly important when navigating the effects of COVID-19 (McCoy-Speight, 2021). However, Murray’s (1995) concern about legislative differences in defining the role of a school counselor remains. Despite evidence describing positive impacts of school counselors on student outcomes, the school counselor role is often misunderstood and continues to vary from state to state (Carey & Dimmitt, 2012). Recently, state differences were most pronounced in Texas Senate Bill 763 (2023), which proposed to equip chaplains to serve as school counselors, and in Florida’s emphasis on parents as resiliency coaches (Florida Governor’s Press Office, 2023). Additionally, factors such as organizational constraints (Alexander et al., 2022), student–counselor ratios (Kearney et al., 2021), and engagement in non-counseling duties (Blake, 2020; Camelford & Ebrahim, 2017; Chandler et al., 2018) continue to hinder the impact that school counselors can make within their school settings. Intrigued by Murray’s observation regarding the long-standing issues with school counseling roles and duties differing from state to state and recent state initiatives to supplement the role of a school counselor with chaplains or parents (e.g., Texas and Florida), we sought to explore how state-level policies and statutes define school counselor roles and responsibilities and how they align with national recommendations.
Defining School Counseling
Noting the need for a uniform definition of school counseling, we turned to ASCA. Although ASCA is not the only professional organization supporting school counselors, it has the longest history (formed in 1952) and largest membership (approximately 43,000). Additionally, ASCA exists for the explicit purpose of supporting school counselors by “providing professional development, enhancing school counseling programs, and researching effective school counseling practices” (n.d.-a, About ASCA section). ASCA (2023) defines school counseling as a comprehensive, developmental, and preventative support aimed at improving student outcomes. ASCA (n.d.-b) advocates for a united school counseling vision and voice among stakeholders. Despite their efforts, researchers, educational leaders, and state policymakers continue to hold varied perspectives about the definitions, needs, and roles of school counselors. Although ASCA (2019; 2023) clearly delineates appropriate and inappropriate school counseling roles and responsibilities, school counselors often find themselves asked to engage in activities deemed inappropriate by ASCA (Bardhoshi & Duncan, 2009; Chandler et al., 2018).
School counselors can use collaboration and advocacy to promote a more appropriate use of their time (McConnell et al., 2020) and to mediate feelings of burnout (Holman et al., 2019). Researchers have discussed the importance of advocacy as integral to pre–school counselor training (Havlik et al., 2019), individual school counseling practice (Perry et al., 2020), and system-wide professional unity (Cigrand et al., 2015). However, such efforts are often limited to a single school or district and often do not include state-level advocacy.
The ASCA National Model
To support their mission of improving student outcomes, ASCA (2019) recommends a national model as a framework for school counselors. The ASCA National Model is aligned with school counseling priorities, such as data-informed decision-making, systemic interventions, and developmentally appropriate care considerations. Implementation is associated with both student-facing and school counselor–facing benefits. In an introduction to a special issue on comprehensive school counseling programs, Carey and Dimmitt (2012) described findings across six statewide studies highlighting the relationship between program implementation and positive student outcomes, including improved attendance and decreases in rates of student discipline. Pyne (2011) and more recently Fye and colleagues (2022) demonstrated correlations between program implementation and school counselor job satisfaction. Pyne found that school counselors with administrative support and staff collaboration related to program implementation experienced higher rates of job satisfaction. Fye et al. noted that as implementation of the ASCA National Model increased, role ambiguity decreased and job satisfaction increased.
The ASCA National Model consists of four components: Define, Manage, Deliver, and Assess. We outline the model in Table 1 below.
Table 1
Four Components of The ASCA National Model
Define |
Standards to support school counselors
School counselors are supported in implementation and assessment of a comprehensive school counseling program by existing standards such as the ASCA Mindsets & Behaviors, the ASCA Ethical Standards for School Counselors, and the ASCA School Counselor Professional Standards & Competencies. |
Manage |
Effective and efficient implementation of a comprehensive school counseling program
ASCA outlines planning tools to support a program focus, program planning, and appropriate school counseling activities. |
Deliver |
The actual delivery of a comprehensive school counseling program
School counselors implement developmentally appropriate activities and services to support positive student outcomes. School counselors engage in direct (e.g., instruction, appraisal and advisement, counseling) and indirect (e.g., consultation, collaboration, referrals) student services. ASCA (2019) stipulates that school counselors should spend 80% of their time in direct or indirect student services. School counselors should spend 20% or less of their time on school support activities and/or program planning. |
Assess |
Data-driven accountability measures to assess the efficacy of program delivery
School counselors are charged with evaluating their program’s efficacy and implementing improvements, based on student needs. School counselors should demonstrate that students are positively impacted because of the counseling program. |
We extend the Assess component to also include research-based examples on factors contributing to a school counselor’s efficacy. Such factors include student–school counselor ratios. For decades, ASCA has advocated for a student–school counselor ratio of 250:1 as well as broader support for school counselor roles (Kearney et al., 2021). Yet, data from the 2021–2022 school year put the average national student–school counselor ratio at 408:1 (National Center for Education Statistics [NCES], 2023). Researchers demonstrate that schools with ASCA-approved ratios experience increased student attendance, higher test scores, and improved graduation rates (e.g., Carey et al., 2012; Carrell & Carrell, 2006; Goodman-Scott et al., 2018; Lapan et al., 2012).
Alternatively, Donohue and colleagues (2022) demonstrated that higher ratios relate to worse outcomes for students. Notably, minoritized students and their school communities often face the brunt of increased student–school counselor ratios (Donohue et al., 2022; Education Trust, 2018). Thus, the ASCA alignment is not only concerned with improved student outcomes but also with the equitable provision of mental health services. Given the role ASCA plays in advocating for and structuring the school counselor’s role and responsibilities, we chose to use the components of the ASCA National Model (2019) as a theoretical framework guiding our study. We have incorporated our theoretical framework throughout, including data collection, data analysis, results, discussion, and implications.
Method
The purpose of our study was to understand how state policies align with the ASCA National Model. We analyzed state policies defining and guiding the practice of school counseling. In any inquiry, the type and characteristics of the data available should dictate the research methods (Flick, 2015). Content analysis allows researchers to identify recurring themes, patterns, and trends (Krippendorff, 2019). By systematically coding and categorizing content, researchers can uncover insights that might not be immediately apparent through casual observation. Additionally, it enables researchers to analyze large volumes of data in a systematic and replicable manner, reducing the impact of personal bias and increasing the reliability of findings. Because of these factors, we found content analysis to be the best method for our inquiry. We chose a subtype of content analysis—problem-driven content analysis (Krippendorff, 2019). Problem-driven content analysis aims to answer a research question. The research question guiding our analysis was: How are state policies aligned or misaligned with the ASCA National Model?
Sample
Using the State Policy Database maintained by the National Association of State Boards of Education (NASBE; 2023), we pulled current policies from all 50 U.S. states and the District of Columbia (N = 51) that dictate the role of school counselors and school counseling services. As ASCA (n.d.-c) describes, terms used for school counseling services can vary, and although “school counselor” is favorable to “guidance counselor,” both terms may be found. However, in NASBE’s State Policy Database, the category was specifically listed as “counseling, psychological, and social services,” and the subcategory was listed as “school counseling—elementary” and “school counseling—secondary” (NASBE, 2023). We included policies that govern kindergarten through eighth grade (K–8) and ninth through 12th grade (9–12). Data included all policies related to school counseling delivery and certification, with State Policy Databases sorted into policies governing K–8 (n = 156, 47.42%) and 9–12 (n = 173, 52.58%) levels, for a total of 329 policies.
Design
From our research question to data reporting, we followed the problem-driven content analysis steps (see Figure 1). We collected language from the policies, including policy type and policy name, and then determined if school counseling was encouraged, recommended, or not specified as either. We built a spreadsheet to divide, define, and identify the state policies into sampling units. We divided them into originating state, policy type, requirements for having school counselors in schools, policy name, and summary of the policy. Additionally, we separated the data into K–8 and 9–12 education designations.
Figure 1
Problem-Driven Content Analysis Process (Krippendorff, 2019)

The analytical process began with filtering policies for inclusion outlined in our selection criteria. We built a spreadsheet to divide, define, and identify the legislative bills into sampling units. We focused on dividing them into originating state, bill number, year, subcategory, and summary of the bill. After completing the spreadsheet with all the data, Kirby Jones and Amanda C. Tracy tested our coding frame on a sample of text. Although content analysis does not require piloting, Schreier (2012) suggested piloting around 20% of the data to test the reliability of the coding frame. We used 20% of our data (n = 66) to conduct pilot coding.
We approached the data analysis deductively, with the components of the ASCA National Model (2019) acting as our initial codes. Prior to analysis, we created a coding rubric that we used to analyze each state’s school counseling policy (see Table 2). We used the four components of the ASCA National Model as the rubric criteria: Define, Manage, Deliver, and Assess. Within each criterion, we developed standards ranging from 1 point to 5 points. We chose point ranges based on the information within each criterion. For example, the Define criterion included three standards for 5 total points. We awarded 1 point if a state required (versus recommended) school counselors in school; we awarded 1 point if a state required school counselors to be licensed and/or certified based on a graduate degree; and we awarded 3 points if a state specifically described all three focus areas of school counseling—academic, college/career, and social/emotional.
Alexandra Frank, Amanda C. DeDiego, and Isabel C. Farrell were involved in creating the rubric and completing initial pilot coding to ensure the usability and utility of the rubric. All team members met throughout the process to ensure workability and fidelity. Following initial testing, each coding pair was trained to appropriately analyze state-level policy data using the rubric. Before finalizing rubric metrics for each state, all team members met again to review metrics and to determine final scores for each state. Importantly, individual state-level rubric scores do not indicate grades, but rather demonstrate evidence of alignment between state-level policy as it is written and the ASCA National Model (2019).
Table 2
Rubric to Evaluate State Policy for Adherence to the ASCA National Model
Aspects of the ASCA National Model |
Define
5 points
|
Manage
1 point |
Deliver
1 point |
Assess
2 points |
Required
1 point
|
Education
1 point |
Focus
3 points |
Implementation
1 point |
Use of Time
1 point |
Accountability
1 point |
Ratio
1 point
|
State has provisions requiring school counselors |
Requires school counselors to be licensed/certified |
Areas of focus include:
(1) academic,
(2) college/career,
(3) social/emotional |
Role includes appropriate school counseling activities |
80% of time spent in direct/indirect services supporting student achievement, attendance, and discipline |
Evaluation of school counselor role included |
Maximum
of 250:1
|
Research Team
Our research team consisted of two counselor educators, two counselor education doctoral students, and one master’s-level counseling student. We began meeting as a research team in summer 2023. Conceptualization, data collection, and analysis occurred throughout the fall, ending in December 2023. Frank, DeDiego, and Farrell continued with edits and writing in 2024. Varying counseling backgrounds (including clinical mental health and school counseling), education settings (e.g., urban, rural, research, teaching), and personal identities were represented. All members are united by a passion for mentorship and advocacy. Additionally, DeDiego and Farrell provided expertise in legislative advocacy and content analysis, and Frank and Tracy provided expertise in school counseling. All members are affiliated with counseling programs accredited by the Council for the Accreditation of Counseling and Related Educational Programs. Frank, DeDiego, and Farrell designed the coding frame and trained Jones and Tracy on the coding process. Frank, DeDiego, and Farrell also resolved any coding conflicts. For example, if a state regulation was unclear, Frank, DeDiego, and Farrell met and decided what code would apply. All members of the research team communicated via email, Google Docs, and/or Zoom meetings to build consensus through the data collection and data analysis processes.
Trustworthiness
To enhance trustworthiness in this study, we followed the checklist for content analysis developed by Elo et al. (2014), which includes three phases: preparation, organization, and reporting. The preparation phase involves determining the most appropriate data source to address the research question and the appropriate scope of the content and analysis. In this phase, we determined the focus of the project to be policy defining school counselor roles; thus, state-level legislation was the most appropriate data source. Use of the NASBE (2023) database offered a means of limiting scope and focus of the content. Using deductive coding (McKibben et al., 2022), we first developed the rubric coding framework based on the ASCA National Model (2019) and then conducted pilot coding to test the framework.
During the organization phase, the checklist addresses organizing coding and theming strategies. We first conducted pilot coding to establish how to apply the ASCA National Model (2019) to coding legislation. We evaluated the content using the rubric to determine how the legislation aligned with the ASCA National Model. Elo et al. (2014) suggested researchers also determine how much interpretation will be used to analyze the data. The coding framework using the ASCA National Model offers structure to this interpretation. Data were coded separately for trustworthiness by Jones and Tracy. Then we met to compare coding. If there was discrepancy, one of us reviewed the data in order to reach a two-thirds majority for all of the coding. By the end of the process, all coding met the threshold of two-thirds majority agreement.
In the Elo et al. (2014) checklist, the reporting phase addresses how to represent and share the results of the analysis. This includes ensuring that categories used to report findings capture the data well and that results are clear and understandable for targeted audiences. The use of a rubric framework offers a clear method to represent and share results of the analysis process.
Results
Our results highlighted trends in the scope and practice of school counseling across the United States. We organized results by rubric strands (Table 3) and by state, analyzing results for K–8 (Appendix A) and 9–12 (Appendix B). We further describe our results within each strand of the ASCA National Model (2019): Define, Manage, Deliver, and Assess.
Table 3
Summary of Rubric Outcomes by Category
|
K–8 |
9–12 |
|
Yesa |
Nob |
Yesa |
Nob |
Required |
37 (72.55%) |
14 (27.45%) |
40 (78.73%) |
11 (21.57%) |
Education |
40 (78.43%) |
11 (21.57%) |
50 (98.04%) |
1 (1.96%) |
Focus
Academic
College/Career
Social/Emotional |
35 (68.63%)
37 (72.55%)
35 (68.63%) |
16 (31.37%)
14 (27.45%)
16 (31.37%) |
40 (78.43%)
41 (80.39%)
40 (78.43%) |
11 (21.57%)
10 (19.61%)
11 (21.57%) |
Implementation |
34 (66.67%) |
17 (33.33%) |
36 (70.59%) |
15 (29.41%) |
Use of Time |
17 (33.33%) |
34 (66.76%) |
10 (19.61%) |
41 (80.39%) |
Accountability |
21 (41.18%) |
30 (58.82%) |
29 (56.86%) |
22 (43.14%) |
Ratio |
2 (3.92%) |
49 (96.08%) |
3 (5.88%) |
48 (94.12%) |
aIndicates awarding of a point, as outcome was represented in the policy.
bIndicates no point was awarded, as outcome was not represented in the policy.
In the state policies, school counselors were designated as required, encouraged, or not specified. For the K–8 level, 72.55% (n = 37) of states required school counselors in schools, 19.61% (n = 10) encouraged the presence of school counselors, and 7.84% (n = 4) of states did not specify a requirement of school counselor presence. At the 9–12 level, 78.73% (n = 40) of states required school counselors in schools, 19.60% (n = 10) encouraged the presence of school counselors, and 1.96% (n = 1) of states did not specify a requirement of school counselor presence.
The category of not specified included policies that were uncodified or policies that did not address the requirement of school counselors at all. The majority of states required school counselors at the K–8 (n = 37, 72.55%) and 9–12 (n = 40, 78.73%) levels. At the K–8 level, one state had a policy that was uncodified (Michigan) and three did not address the requirements of school counselors (i.e., Hawaii, South Dakota, Wyoming). At the 9–12 level, one state had an uncodified policy (Hawaii) and one did not specify a requirement for school counselors (South Dakota). Forty states (80%) for K–8 and 50 states (98.04%) for 9–12 required school counselors to have a license or certification in school counseling. The only state that did not require certification or licensure was Florida. Thirty-five states (70%) for K–8 and 40 states (78.43%) for 9–12 described the role of a school counselor as supporting students’ academic success. Thirty-seven states (72.54%) for K–8 and 41 states (80.39%) for 9–12 described the role of a school counselor as supporting college and career readiness. Finally, 35 states (68.63%) for K–8 and 40 states (78.43%) for 9–12 described the role of a school counselor as supporting students’ social and emotional growth.
Within the Manage aspect of the ASCA National Model (2019), we determined if the state outlined appropriate school counseling activities in alignment with ASCA recommendations in policy or statute (e.g., small groups, counseling, classroom guidance, preventative programs). Thirty-four states (66.67%) for K–8 and 36 states (70.59%) for 9–12 outlined school counseling activities in their policy. For Deliver, only 17 states (33.33%) for K–8 and 10 states (20%) for 9–12 outlined whether or not the majority of school counselors’ time should be spent providing direct and indirect student services.
Moreover, for the Assess category, we evaluated whether the state policy required school counselors to do an evaluation of their role and/or counseling services. Twenty-one states (58.82%) for K–8 and 29 states (56.86%) for 9–12 outlined evaluation requirements. Finally, we evaluated whether the state complied with the ASCA student–school counselor ratio of 250:1. Two states for K–8 (3%; i.e., New Hampshire, Vermont) and three states for 9–12 (5.9%; i.e., Michigan, New Hampshire, Vermont) complied with the recommended ratios. A few states (i.e., Colorado, Illinois, Kentucky, Minnesota, Montana) recommended that state districts follow the ASCA 250:1 recommendation, but it was not a requirement; those state ratios exceeded 250:1.
Next, we examined overall trends of compliance by grade level and by state. For K–8, eight states (15.69%) had higher scores of ASCA National Model (2019) compliance (i.e., Arkansas, Maine, Nevada, New Hampshire, Oregon, Pennsylvania, West Virginia, Wisconsin) compared to other states in our dataset with a score of 8 out of 9. For 9–12, six states (11.76%) scored 8 out of 9 (i.e., Arkansas, Maine, New Hampshire, Pennsylvania, West Virginia, Wisconsin). Excluding Hawaii, South Dakota, and Wyoming, because their state policies did not address the requirements of K–8 school counselors, the states with the lowest scores of ASCA National Model compliance, with 1 out of 9 for K–8 were Alabama, Maryland, Missouri, and North Dakota (n = 4, 7.8%). For 9–12 state policy, two states (3.9%)scored 1 out of 9 (i.e., Massachusetts, South Dakota).
Discussion
Given ASCA’s (n.d.-b) advocacy efforts to develop a unified definition of school counseling, there is a need to assess how those advocacy efforts translate to state policy. Although individual state and district policies shed light on existing discrepancies between school counselor roles and responsibilities, our analysis also provides evidence of alignment with the ASCA National Model (2019) in some areas. These results can inform strategic efforts for further alignment. School counselors can use advocacy to support their role and promote responsibilities more aligned with the ASCA National Model (McConnell et al., 2020). We outline our discussion by again utilizing the four components of the ASCA National Model as a conceptual framework.
Define
Our findings suggest that the Define component of the ASCA National Model (2019) is well-represented in state and district policies. Although our results highlight differences in policy governing practice in K–8 and 9–12 schools, for the most part, all state and district policies required or encouraged the presence of a school counselor. Additionally, the vast majority of states required that individuals practicing as school counselors hold the appropriate licensure and/or certification. Similarly, most state and district policies defined a school counselor’s role as contributing to students’ academic, college/career, and/or social/emotional development. Vigilance in advocacy efforts remains important, as language in policy can change with each legislative session. For example, Texas Senate Bill No. 763 (2023) introduced legislation allowing chaplains to serve in student support roles instead of school counselors. The Lone Star State School Counselor Association (2023) quickly took action with a published brief condemning the language in the bill. As a result of advocacy efforts, lawmakers changed the verbiage in the bill to hire chaplains in addition to school counselors, rather than in lieu of them.
Similarly, Florida’s First Lady, Casey DeSantis (Florida Governor’s Press Office, 2023), announced a shift in counseling services to emphasize resiliency and include resiliency coaches—a role in which “moms, dads, and community members will be able to take training covering counseling standards and resiliency education standards” and provide a “first layer of support to students” (para. 8). Although the Florida School Counselor Association emphasizes advocacy efforts, it has not yet published a response to the changes in Florida’s resilience instruction and support plans (Weatherill, 2023). The legislation in Texas and Florida and the response from state-level school counselor associations highlight, once again, the importance of advocacy for creating and maintaining a uniform definition of school counseling.
Manage
Although ASCA clearly defines appropriate and inappropriate school counseling activities, state policy is less specific on codifying the appropriate use of school counselors’ time and resources. Although most states encouraged appropriate school counseling activities, states did not specifically define appropriate school counseling activities or provide protection around school counselors’ time to implement appropriate school counseling activities. Such findings are consistent with the literature (Bardhoshi & Duncan, 2009; Chandler et al., 2018). Florida’s K–8 policy suggests that school counselors should implement a program that suits the school and department, whereas some states’ K–8 policy, such as New Jersey’s, recommends incorporating the ASCA National Model (2019). Several states include uncodified policy addressing the implementation of a school counseling program. However, as such recommendations are not codified into policy, they do not dictate the day-to-day activities of school counselors. Interestingly, new legislation introducing support roles for chaplains and family/community members only bolsters the need to protect school counselors’ time. Texas Senate Bill No. 763 references the need for support, services, and programming. Florida First Lady Casey DeSantis similarly emphasizes the need for support and mentorship. School counselors are trained professionals equipped to support student outcomes (ASCA, 2019). One wonders whether legislative efforts introducing chaplains and family members would be needed if school counselors’ time was protected in ways to better support students with appropriate school counseling duties. Thus, there remains an opportunity for increased advocacy surrounding the implementation of school counseling programs with specific attention on appropriate versus inappropriate school counseling activities.
Deliver
ASCA suggests that school counselors should spend 80% of their time in direct/indirect services to support student outcomes. Such efforts are pivotal, as research suggests that school counselors play a key role in supporting student outcomes (e.g., Carey & Dimmitt, 2012; O’Connor, 2018). Researchers indicate that school counselors within a comprehensive school counseling program play an integral role in supporting improved student attendance (Carey & Dimmitt, 2012), graduation rates (Hurwitz & Howell, 2014), and academic performance (Carrell & Hoekstra, 2014). However, few states support student outcomes by codifying a school counselor’s use of time into policy. Idaho’s 9–12 policy instructs school counselors to use most of their time on direct services. While not equivalent to ASCA’s 80%, such efforts represent a start to protecting school counselors’ time and ensuring that school counselors are able to make the impact they are well-trained to in their school settings. Similar to Manage, current legislative efforts only highlight the importance of school counselors spending a majority of their time supporting students through direct services.
Assess
ASCA continues to focus their advocacy efforts on student–school counselor ratios with good reason; our findings indicate that 2% of K–8 state and district policies and 3% of 9–12 policies specifically outlined a 250:1 ratio that aligns with ASCA recommendations. Yet, researchers demonstrate that reduced student–counselor ratios support improved student outcomes (Carey et al., 2012; Carrell & Carrell, 2006; Goodman-Scott et al., 2018; Lapan et al., 2012). Further, minoritized students and their communities often face the negative consequences of increased student–counselor ratios (Donohue et al., 2022). As such, further advocacy around student–school counselor ratios is also needed from an equity perspective. Some states, such as Colorado, Illinois, Kentucky, and Montana, recommended ASCA ratios, but as is the case with appropriate versus inappropriate school counseling activities, without policy “teeth” to enforce recommendations, school counselors are often continuing to practice in settings that far exceed ASCA ratios, as is consistent with recent findings (NCES, 2023).
Although many states did not codify policies aligned with the ASCA National Model (2019), several states (North Dakota, New Jersey, Delaware) made reference to the ASCA National Model and recommended alignment. Our analysis supports previous research indicating that advocacy works (Cigrand et al., 2015; Havlik et al., 2019; Holman et al., 2019; McConnell et al., 2020; Perry et al., 2020). Our findings also highlight the value of supporting professional identity through membership in both national organizations and state-level advocacy groups.
Implications
We explored implications for school counselor educators, school counselors, and school counseling advocates. School counselor educators must prepare future school counselors for their roles as advocates. Counselor educators also play an important role in equipping future school counselors with an understanding of the landscape of the profession (McMahon et al., 2009). As such, including state-level policy and district-level conversations in curriculum helps connect counseling students with the evolving policies guiding their work. The rubric created for this research offers a valuable tool to explore state and school district alignment with the ASCA National Model (2019) and demonstrate areas to focus advocacy efforts. Counseling programs often participate in advocacy efforts, such as Hill Day. School counselor educators can use state-level and district-level policy as a springboard to promote specific advocacy efforts with state and local legislation. On a local level, school counselor educators can use our rubric to frame practice conversations for future school counselors to prepare for future conversations with school principals. Finally, school counselor educators can continue engaging in policy-level research to support ongoing school counseling advocacy. School counselor educators can further illuminate the impacts of school counseling policy by describing perspectives of practicing school counselors. School counselor educators can also engage in quantitative research methods to study the relationships between school counselor satisfaction and state policy adherence to the ASCA National Model (2019).
School counselors can use our rubric to analyze alignment of school districts when examining job descriptions during their job searches. School counselors could also use the rubric as part of the evaluation component of a comprehensive school counseling program. From our analysis, it appears most imperative that advocacy efforts focus on school counselors’ use of time and student–counselor ratios. Using data, school counselors can continue to advocate for their role to become more closely aligned to ASCA’s recommendations. Kim et al. (2024) described the “urgent need” (p. 233) for school counselors to engage in outcome research. We hope that our framework provides a tool for school counselors to engage in evaluation and advocacy based on our findings. However, school counselors should not be alone in their advocacy efforts. School counseling advocates, including educational stakeholders, counselors, school counselor educators, and educational policymakers, should continue supporting school counselors by advocating on their behalf at the district, state, and national level.
Future research may focus on the disconnect between state policy and how the districts enact those policies. A content analysis comparing state policy to district rules, regulations, and practices is needed to understand how state policy and district practices align. Finally, although there is frequent legislative advocacy from ASCA, there is a lack of data on state legislators’ knowledge about the ASCA National Model (2019) and ASCA priorities. School counseling researchers can use qualitative methods to interview state legislators, especially after events such as Hill Day, to better detail what legislators understand about the roles and impacts of school counselors.
Limitations
The purpose of content analysis was to discover patterns in large amounts of data through a systematic coding process (Krippendorff, 2019). We are all professional counselors or counselors-in-training with a passion for advocacy. Thus, as with any qualitative work, there is potential for bias in the coding process. Interrater reliability was used to mitigate this risk. There are many factors that impact the practice of school counseling beyond state-level policy. District policies and school leadership vastly impact the ways that state policy is interpreted and enacted in schools. Thus, this content analysis represents only school counseling regulation as described in policy and may not fully represent the day-to-day experiences of school counselors.
Conclusion
Although confusion and role ambiguity muddy the school counseling profession, advocacy efforts and outcome research act as cleansers. By providing a rubric to assess alignment between state policy and the ASCA National Model, we hoped to clarify the current state of school counseling practice and provide a helpful tool for future school counselors, current practitioners, educational leaders, and policymakers.
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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Appendix A
Breakdown of State Rubric Scores for ASCA Alignment for K–8 Schools
|
Define
(5 points)
|
Manage
(1 point) |
Deliver
(1 point) |
Assess
(2 points) |
State Score
(9 points) |
|
Required
(1 point)
|
Education
(1 point) |
Focus
(3 points) |
Implementation
(1 point) |
Use of Time
(1 point) |
Accountability
(1 point) |
Ratio
(1 point) |
Total |
AL |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
AK |
0 |
1 |
2 |
1 |
0 |
1 |
0 |
5 |
AZ |
0 |
1 |
3 |
1 |
0 |
1 |
0 |
6 |
AR |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
CA |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
CO |
0 |
1 |
3 |
1 |
0 |
1 |
0 |
6 |
CT |
0 |
1 |
3 |
1 |
1 |
1 |
0 |
7 |
DE |
1 |
0 |
3 |
0 |
0 |
0 |
0 |
4 |
DC |
1 |
1 |
0 |
0 |
0 |
0 |
0 |
2 |
FL |
0 |
1 |
1 |
0 |
0 |
1 |
0 |
3 |
GA |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
HI |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
ID |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
IL |
0 |
1 |
3 |
1 |
1 |
1 |
0 |
7 |
IN |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
IA |
1 |
1 |
3 |
0 |
0 |
0 |
0 |
5 |
KA |
1 |
0 |
0 |
1 |
0 |
0 |
0 |
2 |
KY |
1 |
1 |
0 |
1 |
1 |
0 |
0 |
4 |
LA |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
ME |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
MD |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
MA |
0 |
0 |
3 |
1 |
0 |
0 |
0 |
4 |
MI |
0 |
1 |
0 |
1 |
0 |
0 |
0 |
2 |
MN |
0 |
0 |
3 |
1 |
0 |
0 |
0 |
4 |
MI |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
MO |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
MT |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
NE |
1 |
1 |
0 |
0 |
0 |
1 |
0 |
3 |
NV |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
NH |
1 |
1 |
3 |
1 |
0 |
1 |
1 |
8 |
NJ |
1 |
0 |
2 |
0 |
0 |
1 |
0 |
4 |
NM |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
NY |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
NC |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
ND |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
1 |
OH |
0 |
1 |
0 |
1 |
0 |
1 |
0 |
3 |
OK |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
OR |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
PA |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
RI |
1 |
1 |
3 |
0 |
0 |
0 |
0 |
5 |
SC |
1 |
1 |
3 |
0 |
1 |
0 |
0 |
6 |
SD |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
TN |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
TX |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
UT |
1 |
1 |
0 |
0 |
0 |
0 |
0 |
2 |
VT |
1 |
1 |
3 |
0 |
0 |
0 |
1 |
6 |
VA |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
WA |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
WV |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
WI |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
WY |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Total |
37 |
40 |
107 |
34 |
17 |
21 |
2 |
– |
Note. Categories refer to the ASCA National Model (2019).
Appendix B
Breakdown of State Rubric Scores for ASCA Alignment for 9–12 Schools
|
Define
(5 points)
|
Manage
(1 point) |
Deliver
(1 point) |
Assess
(2 points) |
State Score
(9 points) |
|
Required
(1 point)
|
Education
(1 point) |
Focus
(3 points) |
Implementation
(1 point) |
Use of Time
(1 point) |
Accountability
(1 point) |
Ratio
(1 point) |
Total |
AL |
1 |
1 |
0 |
0 |
0 |
0 |
0 |
2 |
AK |
0 |
1 |
3 |
1 |
0 |
0 |
0 |
5 |
AZ |
0 |
1 |
3 |
1 |
0 |
1 |
0 |
6 |
AR |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
CA |
0 |
1 |
3 |
1 |
0 |
1 |
0 |
6 |
CO |
0 |
1 |
3 |
1 |
0 |
1 |
0 |
6 |
CT |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
DE |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
DC |
1 |
1 |
0 |
0 |
0 |
0 |
0 |
2 |
FL |
1 |
0 |
1 |
1 |
0 |
1 |
0 |
4 |
GA |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
HI |
0 |
1 |
3 |
0 |
0 |
0 |
0 |
4 |
ID |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
IL |
0 |
1 |
3 |
1 |
1 |
1 |
0 |
7 |
IN |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
IA |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
KA |
1 |
1 |
0 |
0 |
0 |
0 |
0 |
2 |
KY |
1 |
1 |
1 |
0 |
0 |
1 |
0 |
4 |
LA |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
ME |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
MD |
1 |
1 |
3 |
0 |
0 |
1 |
0 |
6 |
MA |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
1 |
MI |
0 |
1 |
3 |
1 |
0 |
1 |
1 |
7 |
MN |
0 |
1 |
3 |
1 |
0 |
1 |
0 |
6 |
MI |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
MO |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
MT |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
NE |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
NV |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
NH |
1 |
1 |
3 |
1 |
0 |
1 |
1 |
8 |
NJ |
1 |
1 |
3 |
0 |
0 |
0 |
0 |
5 |
NM |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
NY |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
NC |
1 |
1 |
0 |
1 |
0 |
1 |
0 |
4 |
ND |
1 |
1 |
0 |
0 |
0 |
0 |
0 |
2 |
OH |
0 |
1 |
0 |
0 |
0 |
1 |
0 |
2 |
OK |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
OR |
1 |
1 |
3 |
1 |
0 |
0 |
0 |
6 |
PA |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
RI |
1 |
1 |
3 |
0 |
0 |
0 |
0 |
5 |
SC |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
SD |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
1 |
TN |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
TX |
1 |
1 |
3 |
1 |
0 |
1 |
0 |
7 |
UT |
1 |
1 |
0 |
0 |
0 |
0 |
0 |
2 |
VT |
1 |
1 |
3 |
0 |
0 |
0 |
1 |
6 |
VA |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
WA |
1 |
1 |
3 |
1 |
1 |
0 |
0 |
7 |
WV |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
WI |
1 |
1 |
3 |
1 |
1 |
1 |
0 |
8 |
WY |
1 |
1 |
2 |
0 |
0 |
0 |
0 |
4 |
Total |
40 |
50 |
121 |
36 |
10 |
29 |
3 |
– |
Note. Categories refer to the ASCA National Model (2019).
Alexandra Frank, PhD, NCC, is an assistant professor at the University of Tennessee at Chattanooga. Amanda C. DeDiego, PhD, NCC, ACS, BC-TMH, LPC, is an associate professor at the University of Wyoming. Isabel C. Farrell, PhD, NCC, LPC, is an associate professor at Wake Forest University. Kirby Jones, MA, LCMHCA, is a licensed counselor at Camel City Counseling. Amanda C. Tracy, MS, NCC, PPC, is a doctoral candidate at the University of Wyoming. Correspondence may be addressed to Alexandra Frank, University of Tennessee at Chattanooga, School of Professional Studies, 651 McCallie Ave, Room 105D, Chattanooga, TN 37403, Alexandra-Frank@utc.edu.
Mar 13, 2025 | Volume 15 - Issue 1
Adriana C. Labarta, Danna Demezier, Alyssa A. Vazquez
Scholars, practitioners, and clients in the eating disorder (ED) treatment field emphasize the need for more culturally responsive approaches to improve care for marginalized communities. Treatment barriers, such as counselor biases, lack of access to care, and disempowering approaches, perpetuate these gaps across diverse groups with EDs. We propose that Ratts et al.’s (2016) Multicultural and Social Justice Counseling Competencies (MSJCC) can bridge these gaps by assisting counselors and other helping professionals working in ED treatment settings in deconstructing biases and implementing empowering treatment approaches for marginalized individuals with EDs. Using case vignettes, we illustrate how counselors can apply the MSJCC across counseling settings and engage in advocacy with the broader ED recovery community. We conclude by presenting implications for counselors, counselor educators, and supervisors, who all play a role in empowering clients and improving access to ED treatment for diverse populations.
Keywords: eating disorder, multicultural, social justice, marginalized, advocacy
The SWAG myth has long persisted within the eating disorder (ED) treatment field, informing research and practice and centering the experiences of “skinny, White, affluent, girls” (Sonneville & Lipson, 2018). Abundant evidence highlighting the presence and impact of EDs across diverse cultural identities now discredits this stereotype (Halbeisen et al., 2022; Huryk et al., 2021; Schaumberg et al., 2017; Sonneville & Lipson, 2018). Nonetheless, scholars, practitioners, and clients alike point to prevailing gaps impacting minoritized populations with EDs and call for more inclusive, culturally informed practice (Burke et al., 2020; Hartman-Munick et al., 2021; Labarta et al., 2023). The American Counseling Association (ACA; 2014) Code of Ethics preamble highlights the importance of “honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts” (p. 3). Thus, multicultural competence is essential for the counseling profession to continue addressing the needs of culturally diverse clients, including social justice concerns that shape and contextualize mental health and wellness. The purpose of this article is to illuminate EDs as multicultural concerns that require counselors to challenge common, harmful stereotypes about EDs and to move toward more inclusive, culturally responsive treatment frameworks.
Multicultural Concerns Within Eating Disorders
Culturally responsive counseling requires counselors to understand clients’ diverse cultural and social identities as well as their mental health experiences (Ratts et al., 2016). Similarly, awareness of the intersection between EDs and multicultural concerns is imperative to culturally sensitive treatment. We begin with an overview of ED literature on underserved populations with particular attention to various aspects of cultural identity, including race and ethnicity, sexual orientation, gender identity, socioeconomic status and food insecurity, ability status, body size, and religion and spirituality. We conclude with a brief overview of intersectionality and ED literature.
Race and Ethnicity
Although racial and ethnic minorities experience EDs at similar rates as non-Hispanic, White individuals (Marques et al., 2011), there is a lack of ED research using racial and ethnic minority samples (Burke et al., 2020; Egbert et al., 2022; Mikhail & Klump, 2021). For instance, Egbert et al. (2022) discovered that across 377 peer-reviewed manuscripts published between 2000 and 2020 in the International Journal for Eating Disorders, only 45.2% reported demographic information related to participants’ racial/ethnic identity. In studies that reported racial/ethnic demographic data, White participants comprised about 70% of the samples. Greater representation of racial and ethnic minorities in research is imperative in order to gain insight into the etiological and maintaining factors of EDs in diverse communities (Egbert et al., 2022), particularly because counselors may hold biases that contribute to significant disparities in ED diagnosis for people of color compared to White individuals (Sonneville & Lipson, 2018). Thus, researchers underscore the importance of exploring culturally and contextually relevant factors, such as sociocultural factors and acculturative stress (Kalantzis et al., 2023; Talleyrand, 2012; Warren & Akoury, 2020) and adopting therapeutic approaches that are collaborative and culturally sensitive (Acle et al., 2021).
Sexual Orientation
Sexual minority populations experience increased risk for ED pathology and may present with higher ED pathology at admission to ED treatment compared to their cisgender, heterosexual peers (Mensinger et al., 2020). However, a recent systematic review examining ED literature from 2002 to 2022 revealed that ED risk varies across sexual minority groups (O’Flynn et al., 2023). Therefore, studies that combine sexual minority groups into one sample may provide an incomplete understanding of ED patterns across distinct identities (e.g., bisexual, gay, lesbian, pansexual). Counselors and researchers should assess sociocultural factors that influence ED risk (Engeln-Maddox et al., 2011) and minority stress experiences (Mason & Lewis, 2015; Meyer, 2003), as well as protective factors that serve as buffers against ED pathology, such as social support. It is important to move “away from heteronormative frameworks and toward more liberatory ones” (O’Flynn et al., 2023, p. 13). It is essential for counselors to recognize the expansiveness of sexuality and attraction, as well as how clients’ identities and experiences inform ED assessment and treatment approaches.
Gender Identity
EDs impact people across diverse gender identities, including gender expansive and nonbinary individuals, transgender men and women, and cisgender men and women (Hartman-Munick et al., 2021; Nagata et al., 2020). However, because of assumptions surrounding EDs as female disorders, men may delay seeking treatment (Räisänen & Hunt, 2014) and feel like “the odd one out” (Kinnaird et al., 2019, p. 848). Nonbinary and transgender individuals with EDs also experience barriers to receiving inclusive care because of gender-based stereotypes (Hartman-Munick et al., 2021). Therefore, it is important for counselors to consider gender norms, ideals, and expressions (e.g., masculinity, femininity, androgyny) that may influence ED pathology and related body image concerns. For example, although EDs are typically associated with femininity and the thin ideal, research has shown that masculinity and muscularity ideals are also risk factors (Griffiths et al., 2015). Counselors should also avoid gender binary assumptions, as individuals who adhere to androgynous ideals are often overlooked in ED assessment and treatment (Cusack & Galupo, 2021). Gender-affirming ED treatment requires deconstructing traditional female-oriented approaches and considering the varied experiences of gender-diverse individuals.
Socioeconomic Status and Food Insecurity
Another common harmful stereotype is that EDs primarily impact individuals of higher socioeconomic status (SES). A recent systematic review debunked this myth when it illustrated that EDs present across varied socioeconomic backgrounds (Huryk et al., 2021). Given that the cost of ED treatment is a significant barrier to care (Ali et al., 2017), individuals of lower SES may be less likely to seek treatment or may have limited access to specialized treatment (Huryk et al., 2021; Sonneville & Lipson, 2018). Relatedly, emerging research has drawn connections between food insecurity and EDs. Existing ED assessment tools often conceptualize food restriction as driven by weight or shape concerns (Hazzard et al., 2020; Middlemass et al., 2021). Individuals experiencing food insecurity, however, may engage in periodic dietary restriction because of fluctuations in food availability, which can lead to bingeing or overeating when food is more accessible (Rasmusson et al., 2019). Given the importance of addressing nutrition in ED treatment, counselors should broach the topic of food insecurity with clients in order to understand patterns of restriction and availability of food (Hazzard et al., 2020; Middlemass et al., 2021). Overall, scholars recommend that practitioners conceptualize SES as a multidimensional construct (e.g., income, occupation, wealth) during the assessment process to determine clients’ barriers and improve access to resources (Huryk et al., 2021).
Ability Status
Individuals with disabilities are largely underrepresented in ED literature even though they are at increased risk of disordered eating behaviors (Cobbaert & Rose, 2023; Gesi et al., 2017; Nazar et al., 2016). Recent research has shown that autistic individuals experience more negative outcomes and barriers in ED treatment than neurotypical individuals (Babb et al., 2021). Cobbaert and Rose (2023) issued a call to action for ED health care professionals to engage in neurodiversity-affirming practices, specifically by rethinking the implementation and practice of ED treatment, which has historically centered the medical model and neurotypical experiences. Current recommendations include using strengths-based, trauma-informed approaches, challenging ableist expectations and treatments, and centering human rights and autonomy (Cobbaert & Rose, 2023). Research also suggests that individuals with physical disabilities have nuanced experiences with body image, which in turn can impact the development of EDs (Cicmil & Eli, 2014; Gross et al., 2000). For example, individuals may develop EDs as a means to cope with the psychological and social difficulties they experience related to living with a disability and navigating societal body image ideals and pressures (Cicmil & Eli, 2014). Ultimately, more research that examines the intersection of EDs and ability status is needed.
Body Size
People of size, or larger-bodied individuals, often experience barriers to receiving quality care, including weight bias from clinicians and delays in being referred to ED treatment (Harrop et al., 2021; McEntee et al., 2023; Puhl et al., 2014). Because of fear of experiencing weight stigma in health care settings, people of size are less likely to seek treatment for health concerns, including EDs (Mensinger et al., 2018). Counselors may perpetuate weight loss–related treatment recommendations that can negatively impact clients’ long-term well-being (Chen & Gonzales, 2022; Puhl et al., 2014). Although larger-bodied individuals may experience significant psychosocial and medical consequences as a result of an ED, research demonstrates that fewer patients are referred to appropriate treatment because of assumptions of severity based on body size (Harrop et al., 2021). Scholars and advocates recognize the need for more research among this population (Ralph et al., 2022) and recommend increased training in the use of weight-inclusive and fat liberation frameworks when working with larger-bodied clients (Matacin & Simone, 2019; McEntee et al., 2023; Tylka et al., 2014).
Religion and Spirituality
Religion and spirituality are critical sociocultural factors that can influence EDs and their treatment. Research has shown that religion and spirituality can serve positive, negative, or non-significant roles in ED recovery based on the individual’s lived experience (Akrawi et al., 2015; Buser et al., 2014; Richards et al., 2018). For example, Akrawi et al.’s (2015) systematic literature review revealed that a secure relationship with God was linked to decreased levels of disordered eating, while a doubtful or anxious relationship with God correlated with greater levels of disordered eating. Religious and spiritual coping strategies (e.g., prayer, meditation, meaning-making, and connecting with nature) can be protective in ED recovery (Buser et al., 2014; Richards et al., 2018). On the other hand, some individuals experience feelings of shame and guilt related to religious beliefs and bullying from members of their religious communities because of their ED (Richards et al., 2018). Because religion and spirituality are often personal and unique to the individual, Mintert et al. (2020) recommend that counselors explore their complex roles and potential relationship to clients’ presenting concerns and integrate evidence-based interventions affirming diverse religious and spiritual identities.
Intersecting Identities
Intersectionality theory, which originates from Black feminist scholarship, describes how multiple marginalized social identities interact and impact mental health (Crenshaw, 1989). Because individuals with marginalized social identities experience inequities related to their ED presentation, counselors must consider the intersection of such identities in order to address specific concerns that impact underserved clients’ risk, treatment process, and outcomes (Burke et al., 2020; Burke et al., 2023). An intersectional approach considers the impact of one identity on another, including how several identities work to either place individuals at risk or support their resilience (Burke et al., 2023). Although more research is needed on EDs across diverse intersecting identities (Burke et al., 2020), scholars have started to explore intersectionality (Burke et al., 2023; Calzo et al., 2017; Diemer et al., 2015). Overall, the higher rates of EDs in marginalized individuals with intersecting identities imply a need for interventions that consider the inequities faced by these individuals and the impact on their risk for EDs (Burke et al., 2023).
Applying the MSJCC to Eating Disorder Treatment
Across ED literature, scholars have advocated for the development of culturally responsive models to address ongoing treatment disparities. We believe that the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016) can serve as a powerful framework for counselors and related helping professionals who work with clients with EDs. The MSJCC, centered on the values of multiculturalism and social justice, attend to essential constructs like intersectionality, including privileged and marginalized statuses within the counseling relationship. Four developmental domains outline essential areas for counselors to explore when working with clients with cultural sensitivity: Counselor Self-Awareness, Client Worldview, Counseling Relationship, and Advocacy Interventions. The first three domains are further organized into four aspirational competencies, namely attitudes and beliefs, knowledge, skills, and action. In the sections below, we review brief case vignettes illustrating various presentations of EDs across diverse intersecting identities, the application of the MSJCC across treatment settings, and relevant resources for counselors.
Counselor Self-Awareness
Paul is a 13-year-old Hispanic, cisgender male with autism spectrum disorder (ASD). He is an only child and lives with his parents and paternal grandmother. Paul’s parents have described him as a picky eater throughout his life. He has an aversion to certain smells and/or textures in food and exhibits rigidity around mealtimes. For example, Paul rarely deviates from his comfort foods and often has the same daily meals, such as plain pasta that his mother prepares for lunch. One day at school, Paul realized that he had forgotten his lunchbox. When his teacher offered to assist him with getting food from the cafeteria, Paul became visibly distressed and began to panic. Paul’s teacher was concerned and contacted the school counselor to check in. Mrs. Walker, the school counselor, called Paul into her office and assessed his concerns, discovering his disordered eating behaviors.
Although Mrs. Walker had experience working with students with ASD, she found herself initially dismissing concerns related to his eating behaviors. After further reflection, Mrs. Walker recognized that her own cultural beliefs and biases related to gender were impacting her ability to fully assess his presenting ED symptoms. For example, she noticed that she held the erroneous belief that males don’t struggle with food. She consulted a colleague on next steps, as she did not want to violate any ethical codes or unintentionally harm Paul. Mrs. Walker began adjusting her attitudes and beliefs. She was surprised to find literature on EDs in males and learned about the unique experiences of those with ASD. Mrs. Walker reflected on internalized stereotypes of gender, disability, and mental health. She was challenged to consider Paul’s unique experience as a young Hispanic male with ASD and the cultural implications of ASD and EDs. To do so, she practiced cultural humility and reflected on her own cultural identities and biases and how they shaped her worldview.
Mrs. Walker sought to learn specific information about the intersection of ASD and EDs, such as their common comorbidity and clinical presentations like sensory sensitivities that may lead to food avoidance (Bourne et al., 2022). Mrs. Walker also used various resources to increase her knowledge of the risk factors of EDs in males, recognizing that risk factors often differ in females. She identified a need to take an individualized approach and developed skills to work with Paul through a culturally responsive lens. Specifically, Mrs. Walker implemented a tailored intervention to empower him and his family to connect with community referrals in order to support his recovery.
Mrs. Walker took action to support her work with Paul by sharing her newly attained knowledge about the intersection of disability and EDs. She initiated a campaign in her school to raise awareness of EDs and gender and disability biases, as well as the challenges that individuals with ASD face during their recovery process. These interventions allowed Mrs. Walker to work toward systemic change surrounding stigma on EDs, males, and people with ASD. She shared a list of local and national organizations that specialize in ASD or EDs (specifically, avoidant/restrictive food intake disorder, or ARFID) with Paul and his family to ensure that they had access to therapeutic support. Examples included Different Brains (https://differentbrains.org) for ASD and the National Alliance for Eating Disorders (https://www.allianceforeatingdisorders.com). Mrs. Walker remains in contact with Paul’s community mental health counselor to understand how she can support him within the school setting. After this experience, Mrs. Walker reflected on the importance of developing her own self-awareness as a counselor, which allowed her to challenge her biases and cultivate more meaningful relationships with diverse students.
Client Worldview
Anita is a 19-year-old Black woman. Growing up in a low-income household, she and her family often struggled with food insecurity, leading to a scarcity mindset around food. Despite these challenges, Anita has always had a close, loving relationship with her family. About one year ago, she came out as pansexual to her parents and a few close friends. Although the experience was positive and empowering, Anita worries about her upcoming transition to college, being away from her family and friends, and connecting with other LGBTQ+ students on her campus. During her first semester, she would binge eat when feeling lonely or stressed. This was usually followed by intense feelings of guilt and shame which led to restriction of food. Anita decided to schedule an intake appointment at her college counseling center; she is scheduled to meet with Dalton, a new counselor who started his position this semester.
Dalton’s goal for the intake appointment is to gain a deeper understanding of Anita’s worldview. Although Dalton has experience working with clients with eating concerns in different settings, he has maintained an assumption that EDs primarily occur in affluent, White populations. Dalton recognizes the importance of challenging his attitudes and beliefs about EDs that could negatively interfere with the treatment process. As Anita shared her story, Dalton intentionally bracketed his biases and remained open to learning about her lived experience. After the session, he engaged in reflective practice by processing his reactions with a colleague at the center with expertise in EDs.
Pulling from his knowledge of culturally responsive theories, Dalton identified the role of intersectionality in Anita’s presenting concerns. As a pansexual woman of color raised in a low-income household, Anita’s experiences may be understood by considering her multiple minority identities. Anita faced significant challenges throughout her life (e.g., food insecurity, the coming out process, and recent transition to college), which may have led to an increased risk of developing an ED. Despite these risk factors, Dalton recognized that an intersectional approach also considers Anita’s strengths and protective factors (Chan et al., 2019), such as strong family support and willingness to seek counseling. Dalton used these insights to conceptualize Anita’s concerns and treatment plan from a strengths-based, culturally responsive lens.
Building on his understanding of theory, Dalton reflected on essential skills to help Anita in counseling. Dalton understood that it may take time for Anita to feel comfortable processing her experiences and sharing parts of her identity. Anita may fear rejection or misunderstanding from Dalton, particularly if he has a different upbringing or cultural background. Dalton understood that experiences of oppression can influence clients’ worldviews and experiences, potentially leading to feelings of disconnection. Given Anita’s complex relationship with food throughout her life, bingeing and restriction may have served as coping mechanisms to deal with uncertainty, loneliness, and fear of rejection. Thus, Dalton remained aware of the inherent power dynamic in the counseling relationship and intentionally shared power with Anita as she navigated her healing process (e.g., co-constructing the therapeutic focus and remaining open to feedback from Anita).
Dalton recognized the need for ongoing commitment, or action, to education and engagement with diverse communities. He sought opportunities to attend workshops or webinars on EDs in underserved populations in order to acquire more awareness, knowledge, and skills related to culturally sensitive approaches. Dalton learned about virtual LGBTQ+ support groups offered by Fighting Eating Disorders in Underrepresented Populations (FEDUP; https://fedupcollective.org) and shared this resource with Anita to expand her social support network. Dalton also reached out to organizations on campus, such as LGBTQ+ and Black, Indigenous, and people of color (BIPOC) student groups, to learn more about their experiences and needs as college students. He consulted with his new colleagues to familiarize himself with student resources, such as on-campus food pantries for food-insecure students. These action-based efforts allowed Dalton to deepen his understanding of Anita’s worldview, immerse himself in the campus community, and advocate for diverse students’ needs.
Counseling Relationship
Jenna is a 40-year-old Jewish Orthodox, heterosexual, cisgender woman who identifies as having a larger body. She experienced significant trauma from her father as a teenager and is now estranged from her immediate family. This has impacted her body image and overall sense of self. Since being estranged, she has struggled with her religious and spiritual identity. Growing up, she learned to cope with difficult emotions with food. She experienced periods of bingeing to help soothe and numb her feelings, as well as periods of significant restriction stemming from attempts to control her body shape. She has reported significant shame regarding her body size and ED symptoms and has avoided seeking counseling because of perceived stigma. Jenna has decided to seek outpatient treatment to help manage ED behaviors after the urging of a friend. When beginning counseling, she realized that she may need to unpack some of her past trauma as well as how religious beliefs have shaped her relationship with food. Jenna began seeing Emily, an agnostic, gay, cisgender female counselor who identifies as “straight-sized,” or a person in a smaller body (Ashwell, 2020). Emily has been working in the field of ED for over 10 years.
While completing the intake assessment with Jenna, Emily asked questions to understand Jenna’s multicultural background. Emily reflected upon her own intersectional identities and how the differences in marginalized and privileged identities may impact the client–counselor relationship. Emily realized that Jenna holds more privilege as a heterosexual woman yet experiences more marginalization because of her Jewish Orthodox identity and larger body size. After the intake session, Emily reflected upon her own attitudes and beliefs about Jenna’s identities, critically evaluating her biases and assumptions, and considered how being in a straight-sized body may impact her client’s comfort or discomfort in the counseling relationship. Emily used curiosity and open communication to strengthen the counseling relationship.
After reflecting on her own attitudes and beliefs, Emily recognized that it was essential to increase her knowledge of her client’s experiences as a Jewish Orthodox woman. Emily learned about Jewish Orthodox beliefs and customs as well as the oppression and discrimination these communities may face. This knowledge was integral to establishing a connection with Jenna and preventing possible microaggressions (Mintert et al., 2020). Because of Jenna’s reported experience with her religious and ethnic background impacting her relationship with food, Emily also focused on exploring intersections between food, body image, and her cultural background.
Emily then explored skills for cultivating an open space for dialogue, particularly those related to addressing how different worldviews between the counselor and client could impact the counseling relationship. Emily demonstrated curiosity and avoided making assumptive statements regarding Jenna’s experiences, understanding the importance of broaching cultural differences in the client–counselor relationship (Day-Vines et al., 2007). Emily’s experience in the ED field prepared her to support clients in challenging diet culture in multiple ways, including discussing the impact of fat-oppressive culture on emotional health, being mindful of her language regarding body size, and creating an inclusive office space for clients in different bodies (Kinavey & Cool, 2019). When Jenna shared discomfort in working on body image issues with an individual in a “straight-sized” body, Emily utilized validation and reflecting skills to process these differences in lived body experiences, which helped Jenna feel safe to further process her body image experiences despite their differences.
Emily took action by holding more conversations with other professionals, joining online communities, and continuing her research to understand how to continue supporting clients of different religious and spiritual backgrounds and body sizes. Emily also supported Jenna in becoming more involved in advocacy, which Jenna found to be empowering and liberating and helped her to improve her relationship with her body. Emily provided resources for Jenna to learn about fat liberation through the Association for Size Diversity and Health (https://asdah.org) and the National Association to Advance Fat Acceptance (https://naafa.org). Emily also connected Jenna to an ED support group, the Larger Bodied Individuals Support Group offered by the National Alliance for Eating Disorders. Emily found that the counseling relationship was strengthened by advocating and taking action with and on behalf of her client.
Advocacy Interventions
Ratts et al. (2016) indicated that counseling and advocacy interventions can occur at several levels (i.e., intrapersonal, interpersonal, institutional, community, public policy, international or global) on behalf of clients or counselors. Counselors are encouraged to consider contextual factors, such as client identities and counseling settings, and to determine the most appropriate and responsive advocacy interventions. The sections above covered several examples of intrapersonal and interpersonal advocacy efforts for counseling clients with diverse intersecting identities. Regarding counselor advocacy, another important intrapersonal consideration is the role of self-care in sustaining social justice and advocacy efforts (Mitchell & Binkley, 2021). The intensive nature of ED treatment (e.g., high mortality and relapse rates; Graham et al., 2020; Warren et al., 2013) emphasizes the need for self-care to maintain vitality and ensure ethical, culturally responsive care. Counselors can also reinforce the significance of wellness practices within their interdisciplinary collaborations that foster interpersonal advocacy within the ED treatment environment.
Counselors can critically evaluate the practices and policies within their institutions and counseling settings to foster inclusion beyond the counseling room. For example, Akoury et al.’s (2019) qualitative study discovered that some women of size experienced physical barriers in therapy waiting rooms, such as unaccommodating furniture. Ensuring that waiting areas and clinical settings accommodate clients of all sizes and abilities is essential to cultivating an affirming environment. It is also worth noting that there are institutional training gaps related to ED education, including within counseling programs (Labarta et al., 2023). Counselor educators and supervisors can address these gaps by adopting a culturally responsive approach to teaching about EDs, improving students’ awareness of EDs across populations, and advocating for the inclusion of ED education across curricula.
Counselors play an essential role in addressing their communities’ mental health needs. The majority of EDs go untreated, especially in minoritized populations (Bryant et al., 2022); thus, community–based advocacy is crucial. One method to more deeply assess these needs is community-based participatory research (CBPR). Because of its strengths-based, collaborative approach, CBPR presents an opportunity for culturally responsive research to address health inequities and disparities impacting underserved groups (Rodriguez Espinosa & Verney, 2021). The core tenets of CBPR involve research with communities, implying shared power in the research process and giving marginalized communities a voice to express their perceptions on gaps and immediate needs (Hays, 2020). CBPR can be a powerful alternative to traditional methods in ED research, which have historically excluded the perspectives and experiences of marginalized groups. Action research methods allow researchers, practitioners, clients, and other stakeholders to collaborate and bridge research–practice gaps, which can improve access to ED and mental health treatment (Rodriguez Espinosa & Verney, 2021).
In addition to CBPR, counselors and other practitioners interested in community-based advocacy for EDs may partner with organizations to raise awareness regarding treatment barriers and challenges. Counselors can support underserved clients with accessing care through organizations like Project HEAL, with its mission to improve equitable treatment access (https://www.theprojectheal.org). Counselors may engage in targeted initiatives (e.g., mental health literacy) to reduce barriers that impact individuals who have an ED that is not yet diagnosed (Griffiths et al., 2018). Culturally responsive awareness campaigns can be initiated and situated within the community to reach individuals who may otherwise not have access to such information. In addition to settings like schools and community agencies, counselors may reflect on specific community venues to support marginalized individuals impacted by EDs, such as barbershops, hair salons, churches, and afterschool centers. Treatment recovery is sustained through early intervention, and increasing awareness may support treatment initiation (Griffiths et al., 2018).
On a larger scale, counselors can engage in public policy initiatives that advocate for improvements in health insurance coverage for ED treatment and research funding (Streatfeild et al., 2021), particularly because ED research remains underfunded compared to other mental health conditions (Austin et al., 2019). Further, remaining up to date on legislation impacting clients with advocacy organizations, such as the National Eating Disorders Coalition (https://www.eatingdisorderscoalition.org), can assist with advancing public policy efforts. Given that EDs are also global issues, international collaborations across disciplines may enhance ED prevention and intervention efforts, allowing for diverse cultural perspectives, deepening our understanding of sociocultural contexts, and extending the impact and reach of social justice and advocacy initiatives.
Implications for Counseling and Counselor Education
Counselors have an ethical responsibility to address the pervasive gaps impacting minoritized clients with EDs (ACA, 2014). The MSJCC are a comprehensive framework that assists counselors with exploring the client’s unique lived experience in addition to relational, systemic, and contextual factors influencing the treatment process (Ratts et al., 2016). The MSJCC can be easily integrated into a counselor’s theoretical approach, leading to a more robust, culturally responsive conceptualization and treatment plan. However, it is essential to note that nuances exist across ED treatment settings, particularly depending on the treatment approach used (e.g., manualized protocols versus individualized treatments). Thus, more extensive conversations within organizations may be necessary, including ways to make the treatment more accessible and inclusive to diverse clients. The MSJCC can serve as a resource to guide these discussions, allowing for a deeper understanding of issues at several levels of treatment (e.g., clients’ experiences, clinicians’ experiences, agency policies and procedures, community issues). For example, FEDUP (formerly Trans Folx Fighting Eating Disorders, 2020) presented a call to action in an open letter to ED organizations, providing essential recommendations, including, but not limited to, the following: hiring more diverse staff at treatment centers, moving away from gender-specific treatment, including inclusive language in handouts and resources (e.g., not defaulting to “she”), establishing scholarships for BIPOC and gender-diverse clients, and developing safe spaces for marginalized clients to connect.
Counselor educators and supervisors also play a role in bridging ED graduate training gaps by utilizing culturally responsive approaches when teaching and supervising ED concerns (Labarta et al., 2023). Suggested pedagogical strategies include applying deliberate practice, addressing countertransference issues, offering specialized coursework, infusing ED education across the curriculum, and collaborating with interdisciplinary professionals to serve as guest lecturers or speakers (Irvine & Labarta, 2024; Labarta et al., 2023; Levitt, 2006). Integrating the MSJCC into the counseling curriculum can assist educators and supervisors in enhancing ED training through a social justice lens. For example, a counselor educator teaching a psychopathology course can encourage counseling trainees to explore how diagnoses can perpetuate weight bias, such as with atypical anorexia nervosa (Harrop et al., 2021), a specified presentation of other specified feeding or eating disorder (OSFED). Counselor educators and supervisors can facilitate discussions on the historical and cultural context of idealized appearance norms, introduce weight-inclusive terminology, explore the limits of research related to weight and health, consider emerging research on fat scholarship, and help trainees remain accountable to their own weight bias and stigmas when working with clients of size (Muzacz et al., 2024; Rothblum & Gartell, 2019). In this way, educators and supervisors encourage trainees to remain critically reflexive of prevalent ED treatment practices and empower their diverse clients with EDs across the lifespan.
Future Research Directions
Scholars have offered several recommendations to enhance culturally informed ED research by creating more inclusive demographic questionnaires and improving reporting in manuscripts (Burnette et al., 2022; Egbert et al., 2022), developing more inclusive assessment tools (Alexander et al., 2024), and designing outcomes-based studies with underrepresented samples (Emelianchik-Key et al., 2023). ED researchers can also use the MSJCC framework to ground their research. For example, counseling researchers have called for more research partnerships between academics and practitioners that can bridge existing research–practice gaps (Barrio Minton et al., 2021; Hays et al., 2019). Related research methods, such as CBPR, can meet this need and incorporate participant perspectives into the research process. Within ED research, this has important implications for marginalized populations who experience barriers to accessing treatment and are often underrepresented in treatment settings. Therefore, moving beyond clinical settings is critical to understanding the unmet needs of community members who may benefit from prevention-based interventions.
Conclusion
In this article, we presented the integration of the MSJCC (Ratts et al., 2016) into the treatment of EDs with marginalized clients. We believe that the MSJCC’s flexibility and social justice lens can assist counselors with bridging the existing gaps and empowering underserved clients across treatment settings. Furthermore, counselor educators and supervisors can utilize the MSJCC as a framework to reconceptualize ED training across counseling curricula, which will play a role in deconstructing dominant narratives on EDs and potentially improving the quality of care for marginalized communities.
Conflict of Interest, Funding Disclosure, and Author Note
The authors reported no conflict of interest or funding
contributions for the development of this manuscript.
The authors would like to thank Hayley Lovelace for
her insights and contributions during the initial
stages of this project.
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Adriana C. Labarta, PhD, NCC, ACS, LMHC, is an assistant professor at Florida Atlantic University. Danna Demezier, PhD, NCC, LMHC, is an assistant professor at Liberty University. Alyssa A. Vazquez, LMFT, is a doctoral student and adjunct faculty at Barry University. Correspondence may be addressed to Adriana C. Labarta, 777 Glades Rd., Bldg. 47, Rm. 274, Boca Raton, FL 33431, alabarta2018@fau.edu.
Mar 13, 2025 | Volume 15 - Issue 1
Brittany L. Prioleau, Shama Panjwani
The integration of diverse and multicultural perspectives in psychedelic-assisted therapy represents an important element within this emerging field. As the therapeutic potential of psychedelics continues to capture the attention of mental health professionals, it is essential to underscore the critical significance of considering the diverse cultural backgrounds, belief systems, and systemic influences and barriers of individuals engaging in these therapies. This article explores the importance of embracing a multicultural and social justice lens within psychedelic-assisted therapy that examines the movement through a historical sociopolitical lens. It reviews the integration of social justice and advocacy into potential treatment, highlighting how psychedelic-assisted therapy has the potential to enhance effectiveness, accessibility, and ethical foundations within the counseling profession.
Keywords: psychedelic-assisted therapy, multicultural, social justice, advocacy, counseling
Psychedelics are substances that alter states of consciousness (Nichols & Walter, 2021). This classification consists of substances derived from roots and plants, including cacti and fungi-like plants as well as synthetic substances that can affect perception. The association of psychedelics with the counterculture of the 60s and 70s created a stigma around usage and thwarted clinical research (Byock, 2018). However, in recent years, psychedelics have reemerged as a breakthrough therapeutic treatment modality for a variety of mental health disorders (Byock, 2018). The emergence of psychedelic-assisted therapy (PAT) and the results of clinical trials demonstrate significant improvements in treatment-resistant depression, increased psychological well-being, and overall long-lasting positive outcomes (Carhart-Harris et al., 2017; Davis et al., 2021; Mitchell et al., 2023; Ross et al., 2016). It is important to recognize the role that counselors and counselor educators will play in embracing diverse and multicultural aspects within the evolving and emerging field of PAT. Many communities of color face disproportionately high rates of mental health challenges because of a number of factors, including access to culturally competent treatment (Viña, 2024). PAT has the potential to address these disparities, but it can only do so effectively when treatment providers are cognizant of systemic barriers that may impact their clients. It is also important to recognize the influences of culture such as aspects of spirituality and the lived experiences from diverse and Indigenous perspectives within psychedelic therapeutic spaces. Psychedelic medicine use has a rich history in traditional cultures (Celidwen et al., 2023). However, the current psychedelic movement, including the research, predominantly represents Western perspectives, while leaders from Indigenous and diverse communities remain absent (Celidwen et al., 2023; George et al., 2020).
Within the current psychedelic science space, the voices and work of Indigenous communities, racial/ethnic minorities, and other historically marginalized populations often go unnoticed (George et al., 2020). Currently, much of psychedelic research excludes voices and perspectives of diverse populations, including those of women and ethnically diverse groups, in both research and practice. These groups must be acknowledged to ensure that they benefit from these novel approaches.
The diverse perspectives and cultural backgrounds of both counselors and their clients are important. In this article, we explore an array of multicultural considerations and address the importance of adopting a multicultural lens in the training and practice of counselors and counselor educators within the context of PAT. We aim to provide insights into and a comprehensive examination of the potential benefits, ethical considerations, and multicultural perspectives related to the potential integration of psychedelic training into counselor education and supervision. We also explore the urgent need for a culturally sensitive and inclusive approach within PAT, with a focus on areas such as cultural appropriation, legalization/criminalization, potential barriers to access, diversity in training, and research and future implications. Acknowledgment of multicultural perspectives in psychedelic therapy presents opportunities toward greater inclusivity and equity while expanding upon traditional healing approaches. Adopting this approach can enhance the efficacy and ethical foundation of these treatments within diverse communities.
Multicultural Considerations in Psychedelic-Assisted Therapy
Psychedelic substances have deep historical and cultural roots in many Indigenous and other traditional practices worldwide (K. Williams et al., 2022). Many Indigenous groups express concern over the cultural appropriation of psychedelics by Western medicine (Celidwen et al., 2023). Understanding the cultural meanings, rituals, and beliefs surrounding traditional plant medicine and psychedelic use can help counselors provide culturally competent care and avoid appropriating or misinterpreting these practices. Therefore, it is important that mental health professionals and educators approach PAT with sensitivity and awareness of diverse cultural perspectives. These considerations align with the American Counseling Association’s (ACA) Social Justice Competencies by encompassing and explaining the cultural contexts of psychedelic use, respecting traditional healing practices, and promoting inclusivity while ensuring equitable access to treatment (Ratts et al., 2016).
Disparities in Psychedelic Research
Current research demonstrates that PAT is emerging as a promising therapeutic approach by offering potentially transformative treatments for a range of mental health–related issues. Early PAT researchers conducted controlled trials that demonstrated the safety and efficacy of psilocybin-assisted therapy in the context of end-of-life distress and cancer-related anxiety, depression, and addiction (Griffiths et al., 2006). The trial showed psilocybin-assisted therapy improved psychological well-being and reduced symptoms of anxiety and depression (Griffiths et al., 2016). In addition, controlled studies conducted in recent years have provided compelling evidence of the potential efficacy of psychedelics in treating mental health disorders, such as treatment-resistant depression, post-traumatic stress disorder, and substance use disorders (Bogenschutz et al., 2015; Mitchell et al., 2023).
The recent clinical trials pertaining to PAT offer great promise and beneficial impacts to mental health and well-being. However, these trials historically have limited the inclusion of Black, Indigenous, and people of color (BIPOC) and other marginalized populations (Michaels et al., 2018; K. Williams et al., 2022; M. T. Williams et al., 2020). For example, a study examining recent PAT clinical trials reported 85% of the participants identified as non-Hispanic White and 5% or less of the participants identified as people of color (Michaels et al., 2018). The lack of participation in the research may be due to factors such as historical mistrust (e.g., trauma linked to medical experimentation), lack of cultural sensitivity, accessibility, stigma and discrimination (e.g., legal ramifications), and non-inclusive recruitment strategies (George et al., 2020; Michaels et al., 2018; Thrul & Garcia-Romeu, 2021; K. Williams et al., 2022). Furthermore, in the most recent phase-2 MDMA trial, only 9.5% of the participants identified as being ethnically diverse (Mithoefer et al., 2011). Subsequently the sample from the phase-3 trial showed improvement toward diverse sampling (Mitchell et al., 2023). In a study examining ketamine-assisted therapy, researchers reported that all clinicians in the trial identified as White, while 89% of the participants also identified as White (Herzberg & Butler 2019). This data has important implications for current and future studies, as current results may not be as generalizable to the greater population (Michaels et al., 2018). Even with the increase and interest in psychedelic-related research, the recruitment and inclusion of diverse populations is lagging. Because researchers have primarily conducted empirical research in psychedelic medicine with a majority of White male participants, there is a lack of knowledge about the impact of PAT on minoritized populations (Viña, 2024). The absence of diverse ethnic and minority population representation may hinder the advancement of PAT. Inclusion of diverse groups may offer the opportunity to customize treatment approaches that may be better suited to people of color.
Cultural Impacts of Legalization
The contexts of sociopolitical landscapes contribute to societal resistance and stigma around psychedelic therapy (Curtis et al., 2020; Hearn et al., 2022). The demonization of psychedelics in the media as well as government campaigns like the war on drugs not only contributed to the stigmatization of these substances and the perception that their use was inherently dangerous, but also fueled fears of a societal impact (Beckett et al., 2006; Sessa, 2016). This resistance can manifest both within counseling communities and the broader cultural context. Additionally, navigating the legal and regulatory challenges associated with multicultural psychedelic therapy adds layers of complexity to its integration into mainstream mental health practice (Marks & Cohen, 2021). The nature of the legalization and criminalization of psychedelic substances has led to hesitancy and resistance among both researchers and mental health professionals (Curtis et al., 2020; Hearn et al., 2022). Resistance to the integration of psychedelic therapy within counseling communities is often rooted in historical narratives, ethical concerns, and misconceptions associated with use (Smith et al., 2022). Many clinicians may fear the legal consequences, professional repercussions, and social stigma surrounding PAT. These impacts may discourage many educators and clinicians from exploring the therapeutic potential of these substances. This could perpetuate a lack of knowledge and formal training within counselor education, leaving educators and clinicians ill-equipped to integrate psychedelics into education and practice. Addressing this resistance requires comprehensive education initiatives within counseling programs. Educators and professional organizations must foster an open dialogue that provides accurate information about the therapeutic potential of psychedelics.
Some jurisdictions have begun to reconsider their approach through a growing recognition of the need for a more evidence-based and compassionate approach to drug policy. States like Oregon and cities like Denver, Colorado, have decriminalized the use of psychedelics (Siegel et al., 2023). The reevaluation of criminalization has opened doors for advancement in scientific research, leading to a resurgence of interest in therapeutic applications (Smith et al., 2022). Moreover, criminalization may limit access to PAT for individuals and communities that may benefit most from these treatments (Devenot et al., 2022). The illegal status of psychedelics presents challenges for patients to find qualified professionals who can provide these therapies legally and safely. Furthermore, the lack of access creates barriers for individuals to explore alternative and potentially transformative treatments for conditions that may be unresponsive to conventional approaches (Smith et al., 2022). Dismantling decades of stigma and overcoming criminalization will require continued advocacy from the counseling profession and mental health field.
Presently, ketamine stands as the only available legal substance that is often classified as psychedelic treatment in the United States. Ongoing research and evolving regulatory landscapes may pave the way for more legal options in the future (Dore et al., 2019). Although most psychedelics remain Schedule I controlled substances, making them illegal for recreational or therapeutic use, practitioners have legally used ketamine to treat treatment-resistant depression. Medical professionals have administered the drug under supervision in various clinical settings, offering hope to individuals who have not responded to conventional antidepressant therapies (Dore et al., 2019; Marks & Cohen, 2021). In the past, the legal classification of psychedelics as Schedule I substances, coupled with strict regulations, have made it challenging for researchers to obtain the necessary approvals and resources to conduct studies. However, researchers have put forth guidelines for testing psychedelics (Johnson et al., 2008). Although more federally funded clinical trials have emerged to highlight the benefits of PAT in recent years, underground use of the substances in community, therapeutic, and spiritual contexts has disproportionately impacted diverse and Indigenous communities (Williams et al., 2022). Furthermore, even with evidence of potential benefits of PAT, state and federal regulatory guidelines create barriers for the use of psychedelics in treatment (Byock, 2018).
Impacts of Criminalization
The current sociopolitical climate and the overcriminalization of drug use continue to further stigmatize communities of color (Ching, 2019). Almost half of incarcerated individuals are in prison because of drug-related offenses (Buehler & Kluckow, 2024). Black men are imprisoned at a 5.7% higher rate than their White counterparts for similar convictions (Buehler & Kluckow, 2024). Racial disparities among drug arrests continue to persist. Because of these factors, people of color may feel less safe from a legal standpoint and may display more hesitancy to explore psychedelic-related therapeutics (George et al., 2020). People from historically marginalized communities may also be resistant to the use of psychedelics and PAT because of these implications (Ching, 2019). Additionally, psychedelic medicine has been underutilized to treat issues such as race-based trauma within communities of color. A study conducted by M. T. Williams et al. (2021) found a significant reduction in anxiety and depressive symptoms in participants who utilized psychedelics for the treatment of race-based trauma. However, if clinicians are not properly trained and do not understand the mechanics of racism, they can add to their clients’ trauma (Smith et al., 2022). In addition, researchers have argued that the current psychedelic-assisted model of therapy does not properly train counselors to treat BIPOC populations (Smith et al., 2022).
On a broader cultural level, because stigma surrounding psychedelic use persists, it often hinders individuals from diverse backgrounds from considering or openly discussing PAT (George et al., 2020). This stigma is rooted in societal misconceptions, fears, and historical prejudices; it may also include mistrust of the practitioners engaging in this mode of therapy (Smith et al., 2022). Addressing this stigma requires collaborative efforts between mental health professionals and community leaders. Public awareness campaigns that are culturally sensitive as well as education programs and community engagement initiatives can be utilized to challenge stereotypes and misinformation. These efforts should not only emphasize the potential benefits but also any associated risks of PAT. These efforts can assist in the destigmatization of PAT and validate its use as a legitimate therapeutic modality. Without legal access to psychedelic-assisted therapeutic modalities, historically marginalized populations remain vulnerable to criminalization. Advocacy efforts should focus on disseminating information geared toward acknowledging past drug policy harm and the potential for psychedelic healing. Addressing these barriers through advocacy and policy are essential to ensuring equitable access.
Ethical Considerations
The historical use of these substances for spiritual, cultural, and personal purposes challenges the notion of gatekeeping and medicalization. Therefore, ethical considerations extend beyond therapeutic settings to also encompass the possible recreational use of psychedelics (Pilecki et al., 2021). Gatekeepers who limit access to these substances raise questions about equity and personal autonomy. At the same time, there is a risk of overly medicalizing psychedelics, which may strip away the rich cultural and spiritual heritage that has been integral to their use.
Cultural Appropriation and the Commodification of Psychedelic Experiences
Incorporating diverse and multicultural perspectives into the framework of PAT presents ethical challenges, particularly concerning the risk of cultural appropriation. Cultural appropriation refers to the adoption or use of elements from one culture by individuals or groups, often from a more dominant culture, without understanding, respect, or permission (Sue et al., 2022). Issues may arise in the context of PAT when people appropriate cultural practices or substances with deep historical or spiritual significance. One of the primary ethical considerations revolves around the respect for Indigenous knowledge and practices. Indigenous cultures have utilized psychedelic substances in their spiritual and healing rituals for centuries, and the current psychedelic movement faces challenges with the cultural and historical appropriation of these traditional healing methods (George et al., 2020). The appropriation of these practices without the involvement, permission, or benefit of Indigenous communities raises substantial questions about cultural exploitation and ethical responsibility. For example, the financial exploitation of plant medicines, without direct benefit to Indigenous peoples, could lead to unsustainable extraction of plant medicines, making them unavailable for communal use (Celidwen et al., 2023).
Indigenous and other cultures from around the world have long-standing traditions of working with psychedelic substances for spiritual and therapeutic purposes (Field, 2022). Many Indigenous cultures position the aspect of spirit as an integral component of healing and understanding (Field, 2022). The exploration and use of psychedelics in therapeutic contexts must confront the ethical challenges associated with cultural appropriation and the commodification of psychedelic experiences, which may exclude aspects of spiritual influences. Some may argue that in many Western-based PAT options, there is often an absence or underrepresentation of the integration of spiritual or transcendental aspects (K. Williams et al., 2022). Studies have shown that participants who undergo PAT, such as psilocybin-based therapy, highly correlate mystical or spiritual experiences with treatment (Reif et al., 2020). Although these treatments primarily focus on the clinical and therapeutic benefits of psychedelics, they may sometimes overlook the profound spiritual or mystical experiences that these substances can induce (Griffiths et al., 2006). The subjective nature of spirituality and the hesitance to incorporate it into scientific and clinical models that seek measurement of experiences as validation methods may be contributing factors (Sessa, 2016; K. Williams et al., 2022). However, for many individuals, the spiritual dimension of their psychedelic experiences is deeply meaningful and transformative (Griffiths et al., 2006). Recognizing the spiritual aspects and the potential for personal growth, healing, and enhanced well-being is important in order to offer a comprehensive and holistic approach to psychedelic therapy. This approach respects the diverse ways in which some individuals find meaning and make connections through these experiences.
Medicalization and Decolonization
The historical exploitation of Indigenous practices, including the appropriation of sacred rituals, also encompasses commercialization of psychedelic substances (Devenot et al., 2022). Because of a number of promising studies, many companies and entities are positioned to profit from the therapeutic potential of psychedelic medicines by seeking to patent psychedelic substances (Marks & Cohen, 2021). Marks and Cohen (2021) argued that this may allow a small number of companies to act as gatekeepers, further restricting access to these emerging therapies. However, many marginalized groups, including Indigenous populations, do not receive these benefits (George et al., 2020; K. Williams et al., 2022). By not acknowledging the cultural roots of classic psychedelics, the colonization and appropriation of these practices may result in the erasure and exploitation of Indigenous knowledge and traditions (K. Williams et al., 2022). Mental health professionals engaging with psychedelic therapy must critically examine and address these concerns to ensure ethical and respectful practices.
As a profession, counselors must ensure that the voices of all cultures, including those who have stewarded plant medicines for millennia, are not lost and that advocacy becomes part of the PAT framework in order to create a more equitable future for all. Counselors should approach these practices with humility, respect, and a commitment to cultural preservation. PAT must acknowledge and address power dynamics, particularly in the context of historical and ongoing debate concerning the use of psychedelic substances. The Multicultural and Social Justice Counseling Competencies provide a guide for praxis to address these issues (Ratts et al., 2016). The current focus on medicalization and profit can overshadow the cultural, spiritual, and therapeutic significance of psychedelic experiences (Devenot et al., 2022; Schwarz-Plaschg, 2022). Furthermore, medicalization attempts to position Western approaches to Indigenous practices as the only legitimate way to utilize these substances may lead to restrictions and regulation of access (Schwarz-Plaschg, 2022). Mental health professionals need to recognize the impact of colonialism on Indigenous practices and the potential for appropriation of psychedelic plant medicines (Sessa, 2016). Educators and practitioners should actively work to dismantle power imbalances by engaging in ethical collaborations to promote the inclusion and empowerment of historically marginalized communities.
The Role of Counseling in Advocacy, Access, and Equity
PAT shows promise for addressing major facets of mental health disparities, particularly among vulnerable and underserved communities (Thrul & Garcia-Romeu, 2021). These communities often face higher rates of mental health–related issues, including trauma, depression, anxiety, and substance abuse, and they could potentially benefit significantly from these innovative therapies (Thrul & Garcia-Romeu, 2021). Counselors should prioritize access to these treatments in communities that are often disproportionately affected by mental health challenges (Herzberg & Butler, 2019; Michaels et al., 2018; Sevelius, 2017; Thrul & Garcia-Romeu, 2021; Williams & Labate, 2020). Psychedelic therapy should strive for equitable access, ensuring that individuals from all backgrounds can benefit from this modality. This requires addressing barriers such as costs and accessibility. Mental health professionals should work toward making PAT accessible and affordable (Herzberg & Butler, 2019; Michaels et al., 2018). This is particularly relevant for economically marginalized communities that have historically faced barriers to accessing quality mental health care. Many individuals from underserved and marginalized communities may face financial limitations that present as a barrier and could potentially limit access, preventing them from pursuing these investigative treatments (K. Williams et al., 2022). For PAT to be equitable, it is essential to consider financial accessibility. Being proactive and advocating for insurance coverage of PAT could significantly enhance access. This, in turn, can increase health and social disparities faced by these communities. As the field of PAT evolves, addressing these issues becomes increasingly important. Counselors must ensure future equitable access to PAT, as equity aligns with the broader goals of counseling and fundamentally links the idea that everyone, regardless of their cultural or socioeconomic background, should have access to innovative and effective mental health care.
Advocacy for policy changes is crucial for improving access to and equity in PAT. Counselors, counselor educators, and the broader mental health community can play a significant role in advocating for policy changes and greater access as these modalities become further legalized. Legal reforms can help decriminalize psychedelics and regulate access to PAT. The creation of standardized training and evidence-based guidelines is essential for those who wish to integrate PAT into their practice (Marks & Cohen, 2021).
Furthermore, counselors can embed PAT in a broader framework of multiculturalism and social justice advocacy by aligning it with the counselor social justice advocacy competencies. (Ratts et al., 2016). This involves addressing historical and ongoing injustices and actively working toward decolonizing practices and systems. Educators and clinicians engaging with PAT should recognize their role in advancing social justice and commit to principles of equity, inclusivity, and cultural empowerment. By approaching PAT with cultural humility and a commitment to ethical practice, professionals can contribute to a more inclusive, respectful, and responsible approach.
Moreover, multicultural perspectives bring depth to the therapeutic process itself. Different cultures have their unique healing practices, spiritual beliefs, and worldviews regarding altered states of consciousness. By embracing multicultural perspectives, counselors can expand their understanding of healing, embrace diverse approaches to well-being, and tailor PAT to meet the specific needs of individuals across cultural backgrounds (Sevelius, 2017). Promoting diversity and inclusivity within the field by training, providing educational opportunities to individuals from diverse backgrounds, and prioritizing the inclusion of diverse perspectives in research and practice can help promote equity. Development of inclusive policies that address historical injustices as well as ethical and cultural considerations aimed at reducing disparities in access related to psychedelics is crucial (M. T. Williams et al., 2020).
Multicultural Perspectives, Strategies, and Implications for Practice
Integrating multicultural perspectives into counseling practice is important for fostering inclusive and effective mental health care, particularly in emerging fields like PAT. Integrating diverse viewpoints and practices can help address systemic barriers, promote inclusivity, and enhance therapeutic outcomes for marginalized populations and other underrepresented groups. By addressing issues related to diversifying psychedelic research, diversifying the counseling workforce, and emphasizing culturally responsive approaches, counselors can create spaces that address diverse experiences. This section outlines actionable steps and strategies designed to incorporate multicultural frameworks into training, research, and practice.
Psychoeducation for Advocacy in Psychedelic-Assisted Therapy
Counselors play a pivotal role in advocacy efforts for PAT by providing psychoeducation that empowers everyone—clients, marginalized communities, and the general public. Counselors can tailor psychoeducation to address the historical use of psychedelics and tackle issues related to marginalized populations, including common barriers to access. One strategic approach is to have counselors engage with clients and communities and educate them about the current changing legal landscape surrounding psychedelic substances, which includes regulatory changes and clinical trials that are shifting the conversation toward wider acceptance (Nichols & Walter, 2021). Providing accurate information about the safety, efficacy, and cultural history of psychedelics, specifically in non-Western and Indigenous contexts, can help reduce stigma and promote informed decision-making (George et al., 2020).
Additionally, professional counselors can offer a variety of workshops and community outreach programs that discuss the therapeutic potential of psychedelics and address concerns specific to underserved communities, such as fears of legal ramifications or historical trauma linked to medical experimentation (George et al., 2020; K. Williams et al., 2022). Legal reforms will help decriminalize psychedelics and regulate access to PAT. This approach should be culturally responsive to ensure that materials and discussions are tailored to the needs, values, and historical experiences of these populations.
Lastly, counselors can advocate for systemic change by collaborating with state and local organizations and policymakers to disseminate information about the potential benefits of PAT, specifically for treating trauma-related disorders in communities of color (Doblin et al., 2019; M. T. Williams et al., 2020). Counselors must also advocate for insurance coverage by lobbying through a call for action to reduce financial barriers for marginalized groups. Through a psychoeducational approach, counselors will advocate for more equitable access to PAT.
Diverse Representation in Psychedelic Research
Discussing multicultural approaches in PAT helps researchers and counselors develop cultural competence, address biases, tailor treatment to individual needs, foster trust, empower clients, and promote social justice. By embracing a multicultural lens, researchers can create more effective and inclusive protocols for care that respect and acknowledge the diverse cultural backgrounds and identities of their clients (Scharff et al., 2010). Considering cultural factors in research of PAT is essential to ensure that therapy is relevant, respectful, safe, and inclusive (George et al., 2020). It promotes cultural sensitivity that acknowledges the diversity of human experiences, which aids counselors in providing effective and meaningful support to their clients so that PAT is accessible to individuals from diverse cultural backgrounds.
Diverse representation requires cultural sensitivity training to produce culturally competent research teams consisting of clinicians, researchers, and support staff. One strategy is to offer training that focuses on respecting and understanding diverse beliefs, values, cultural practices, and communication styles (Brennan & Belser, 2022). Diverse representation also entails having culturally different populations as participants in clinical trials. Engagement and collaboration must be addressed when tailoring recruitment strategies, dealing with barriers to access, enhancing language accessibility, and combating historical stigma through community education (Herzberg & Butler, 2019). Recruitment strategies using educational programs that specifically target underrepresented groups should involve culturally relevant communication channels to reduce stigma and increase awareness about psychedelic research within diverse communities.
Partnerships with community organizations and collaboration with community leaders will promote insight into specific cultural nuances and values and help build trust within diverse communities (Williams & Labate, 2020). Ethical considerations, including informed consent, privacy, and confidentiality, must be carefully addressed while also respecting and integrating the cultural contexts and values of participants (Smith et al., 2022). Along with increasing awareness, collaboration identifies barriers, such as financial constraints and transportation, that prevent marginalized individuals from participating. Adapting PAT protocols by incorporating traditional healing practices and spiritual elements that are meaningful to participants from diverse backgrounds creates additional cultural sensitivity around including culturally different populations (Celidwen et al., 2023). Diverse representation in psychedelic research is not only an ethical imperative, as outlined in the ACA Code of Ethics (ACA, 2014), but also is essential for producing results that impact diverse populations. It is vital to ensure that individuals from a broad spectrum of cultural and ethnic backgrounds understand the benefits and risks of PAT.
Diversifying Psychedelic Training and Workforce
Specific guidelines for PAT vary and remain unclear (Schwarz-Plaschg, 2022). Moving forward, it is imperative that the counseling profession and governing bodies work together to create diverse training and treatment modalities. Furthermore, it is important that future PAT is reflective of people from diverse backgrounds to better fit the needs of people of color. Many current protocols and training programs are developed without input from diverse voices, which can result in a lack of cultural awareness regarding participants’ experiences (Buchanan, 2020). Incorporating a diverse array of clinicians from various backgrounds into psychedelic therapy training is a crucial step in ensuring the cultural relevance and effectiveness of these therapeutic approaches. Ensuring clinicians are culturally competent in training will help to build trust and rapport with clients from diverse backgrounds. Addressing mental health disparities within marginalized communities will also aid in culturally appropriate treatment approaches. Clinicians of color and clinicians from other diverse backgrounds bring valuable perspectives and cultural insights that enrich the field and promote a more inclusive, equitable, and effective approach to psychedelic therapy. Having a diverse workforce also aligns with and promotes the broader principles of social justice and health care equity. In the current landscape of psychedelic research and practice, people of color and women are often overlooked as leaders (Buchanan, 2020; George et al., 2020). Diversity in the workforce also reinforces the importance of making access to PAT equitable through representation. One strategy for diversifying the workforce is to encourage counseling programs to partner with other PAT training programs and offer scholarships and fellowships for training that create educational opportunities for marginalized students, thus promoting diversity and inclusivity. These scholarships and fellowships can specifically fund trainings for historically marginalized students.
As the counseling profession begins to explore ways to incorporate PAT into counselor training, embedding multicultural counseling competency as a foundational element of their PAT curriculum is recommended. One example could include introducing PAT in a counseling theories course as an emerging therapeutic framework to potentially treat treatment-resistant disorders. Exploration of PAT can also be included in a multicultural counseling course. This requires the inclusion of coursework that explores the history, cultural significance, and modern therapeutic applications of psychedelics across different cultures. Students should learn how various communities have actively integrated psychedelics into their healing practices for centuries, particularly in regions where plant medicines play a central role in traditional health and spiritual rituals.
Counseling programs may also include courses that provide specific training on addressing the cultural and historical trauma that may arise in clients from marginalized communities. For instance, the war on drugs disproportionately impacted Black and Indigenous communities in the United States, which may influence how they perceive psychedelics and PAT (Buchanan, 2020; Carhart-Harris et al., 2017). Counselors must receive training on acknowledging and addressing historical traumas when working with clients from these backgrounds, utilizing trauma-informed approaches that validate their experiences and build trust (Williams & Labate, 2020).
In addition, counselors must develop skills in culturally relevant communication to effectively engage with clients from various backgrounds. This includes being mindful of how different communities and clients may interpret the psychedelic experience. For example, some Indigenous groups may share experiences through a spiritual or shamanic lens, while others may relate their experience to their unique cultural background. Counselors should receive training from culturally competent PAT practitioners and established PAT programs to adapt their communication styles to respect cultural nuances and avoid the imposition of a singular Western therapeutic approach (George et al., 2020).
Community Collaboration
Collaborating with diverse communities in the context of PAT is crucial for fostering culturally sensitive practices that honor traditional knowledge and ensure ethical integration into modern therapeutic frameworks. A potential strategy is for counselors to form community partnerships with individuals from the cultures whose practices are being integrated and ask these individuals to offer valuable insights and guidance on ethical considerations. An example from the literature describes panels from Indigenous communities creating a list outlining eight ethical considerations for engaging in psychedelic medicine. They include concepts pertaining to Indigenous knowledge, nature, and ways of being and knowing (Celidwen et al., 2023). These panels can help ensure that cultural perspectives are appropriately integrated into the therapy process. Moreover, collaboration with Indigenous and other cultural communities should involve mutually agreed-upon benefit-sharing arrangements. These arrangements can include providing financial support, resources, or other forms of reciprocity to recognize the value and utilization of the used cultural knowledge. Collaborating with Indigenous communities and leaders through engagement and partnerships can guide the creation of culturally sensitive and ethically appropriate practices and training while incorporating traditional healing and spiritual elements into research and training protocols. This collaboration can help create culturally competent research teams with diverse representation that can aid in recruiting underrepresented groups for clinical trials through education and trust building. This continual evaluation helps minimize cultural appropriation and preserves cultural sensitivity, which aligns with ethical principles that promote inclusivity, respect, and justice. These principles correspond with the multicultural and social justice advocacy competencies (Ratts et al., 2016).
Conclusion
Looking ahead to the future of counseling in psychedelic therapy, it is essential to acknowledge and honor the Indigenous and other cultural history and traditional use of these substances. Many cultures have maintained profound relationships with psychedelics as healing tools for generations by utilizing them in sacred rituals and healing practices (Fotiou, 2020). This cultural context offers valuable insights into the therapeutic potential of these substances and underscores the need for cultural humility and acknowledgment within the field of PAT. Recognizing Indigenous knowledge and practices not only informs our approach, but it also highlights the importance of collaborating with these communities and leaders (George et al., 2020). By doing so, counselors can foster a more inclusive and equitable future for PAT.
By acknowledging the diverse ways in which individuals experience healing, PAT has the potential to break down barriers and reduce mental health disparities. The future of PAT rests significantly in the hands of counselors and other mental health professionals. Additionally, culturally competent and inclusive psychedelic training can address disparities and promote equity in mental health services. As ambassadors of mental health and well-being, counselors can play a pivotal role in shaping the narrative around PAT. Educators bear the responsibility of imparting the knowledge, skills, and cultural competence required to navigate this evolving landscape. Incorporating psychedelic education into counseling programs equips future professionals with the skills to meet the diverse needs of their clients. Counselors can assist in these efforts by actively engaging in destigmatizing PAT, advocating for legal reforms, and promoting cultural humility that recognizes the significance of multicultural perspectives. Embracing multicultural perspectives in PAT is not merely an ethical imperative; it is a guide toward a more compassionate and holistic vision of mental health and well-being. Counselors, as educators, clinicians, and advocates, have the potential to shape a future that integrates the potential significance of PAT with cultural competence, offering profound respect of diverse experiences.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Brittany L. Prioleau, PhD, NCC, ACS, LPC, CIMHP, is an assistant professor at Mercer University. Shama Panjwani, PhD, NCC, LPC, is an assistant professor at Keiser University. Correspondence may be addressed to Brittany L. Prioleau, 3001 Mercer University Dr., Atlanta, GA 30341, prioleau_bl@mercer.edu.
Jan 17, 2024 | Volume 13 - Issue 4
Sunanda M. Sharma, Jennifer E. Bianchini, Zeynep L. Cakmak, MaryRose Kaplan, Muninder K. Ahluwalia
According to the American Counseling Association and the Council for Accreditation of Counseling and Related Educational Programs, social justice advocacy is an ethical imperative for counselors and a training standard for counseling students. As a group of socially conscious mental health counseling students and faculty, we developed and facilitated a social justice advocacy group to learn about tangible ways to engage in social justice action. Using the S-Quad model developed by Toporek and Ahluwalia, we formed and facilitated a social justice advocacy group for our peers. This paper will serve as a reflection of our experiences engaging in the process.
Keywords: social justice, advocacy, counseling students, S-Quad model, mental health
When describing the motivation for her political aspirations, Georgia gubernatorial hopeful Stacey Abrams (2019) stated, “We have to have people who understand that social justice belongs to us all.” This quote speaks to this group of authors who feel strongly about the importance of social justice in mental health counseling. This ethos served as the motivation to create a peer-led group to foster the development of our social justice advocacy skills. We used the S-Quad model (Toporek & Ahluwalia, 2020) to form and facilitate a social justice advocacy group for master’s and doctoral counseling students at our institution.
Historically, the counseling profession has been rooted in social justice advocacy (SJA) with Frank Parsons’s efforts to support White European immigrants in the United States to develop their vocational goals (Gummere, 1988; Toporek & Daniels, 2018). However, SJA has not been consistently operationalized across counselor training programs (Counselors for Social Justice [CSJ], 2020). Although ethical standards established by the American Counseling Association’s ACA Code of Ethics (ACA; 2014) encourage counselors to advocate for clients and communities when appropriate (A.7.a, A.7.b.), and training standards established by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) state that SJA should be a part of counseling curriculum (2.F.2.b.), counselors have reported receiving little guidance about how to implement advocacy in practice (Field et al., 2019; Ratts & Greenleaf, 2018). As counseling students, we experienced the same concern. To address this gap in our educational experience, we created and facilitated a group based on the S-Quad model (strengths, solidarity, strategies, and sustainability) of SJA (Toporek & Ahluwalia, 2020). As a group of socially conscious mental health counseling students, our aim was to grow in our roles as professionals by learning about, teaching, and engaging in SJA. In the process, we learned about ourselves as budding counselors and educators.
Literature Review
In their foundational article, Vera and Speight (2003) called on the counseling profession to expand its understanding of multicultural competence; they asserted that without SJA, counselors are perpetuating the systems of oppression from which their clients are attempting to heal. Utilizing intrapsychic approaches which neglect to account for contextual factors not only perpetuates oppressive counseling practices, but it also does a disservice to those with marginalized identities (Ratts, 2009; Vera & Speight, 2003). In order to properly serve clients, counselors must step beyond the classroom, expand the original conceptualization of our roles, and explore beyond the counseling office (Ratts, 2009; Ratts & Greenleaf, 2018; Vera & Speight, 2003). Despite the increase in available resources such as the ACA Advocacy Competencies (Toporek et al., 2009) and the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016), the number of sociocultural forces such as racial demographics of counseling programs and reliance on theories and interventions developed for White European clients prevents social justice from being a central force in the profession (CSJ, 2020).
As mental health professionals, we are positioned to understand the impact that oppression has on health (Nadal et al., 2021), which speaks to the need for operationalizing social justice counseling and SJA so counselors may support client wellness. Counseling students require more knowledge and practice to obtain appropriate resources and tools in order to intervene and resist systemic oppression (Vera & Speight, 2003). Ratts (2009) named social justice as the “fifth force” in counseling in an attempt to concretize the relevance and importance of challenging the status quo in counseling. However, the perceived attitude of the counseling profession toward social justice is reflected in the definition of counseling. The 20/20 initiative was a movement to unify the profession and solidify professional identity by arriving at the definition of counseling. Delegates from 31 counseling-related organizations (e.g., CACREP, Chi Sigma Iota) participated in a Delphi-method study to achieve consensus on a definition; however, only 29 organizations ultimately endorsed the definition (Kaplan et al., 2014). Although the definition for counseling includes the word “empower”; it does not include the words “social justice” or “advocacy.” Thus, CSJ was one organization that did not support the new definition (Kaplan et al., 2014). Despite these challenges, Ratts and Greenleaf (2018) assert that counselors must develop the advocate part of their identity, yet they note that there is more of a focus on traditional counseling skills rather than acknowledging the shifting sociopolitical climate and equipping counselors with the skills to address these concerns. The leadership and advocacy course (or the content in another course; CACREP, 2023) in CACREP-accredited counseling doctoral programs often only focuses on leadership and advocacy within and for the profession. Although CACREP (2023) standards do not dictate the courses a counseling program must offer, there continues to be limited discussion of SJA and social justice, nor are there solid instructional methods for counselor educators to use in the classroom (Chapman-Hilliard & Parker, 2022). This situation hinders students’ understanding of the role systemic issues have on minoritized communities, further deterring people in those communities from seeking help.
As counselors and counseling students, we understand our responsibility to advocate for clients, but we feel unprepared to fulfill our ethical (and for many of us, moral) duty. We did not learn enough about the concrete, tangible skills that a professional counselor can utilize to challenge oppression and inequity. We were unable to locate any studies regarding peer-led SJA groups for counseling students, thus we hope to contribute something novel to the counseling literature and encourage counseling students to better understand and grow into their roles as social justice advocates. Counselors-in-training (CITs) and practicing counselors within the profession sometimes question the relevance of SJA and report feeling confused about how to implement SJA in counseling (Field et al., 2019; Ratts & Greenleaf, 2018). hooks (1994) notes it is imperative that a student accepts responsibility for their education and becomes “an active participant, not a passive consumer” (p. 14). Thus, we engaged in this process to support our colleagues in the counseling student body and take accountability for our education.
Taking Action: Social Justice Advocacy Group
Leading organizations in the profession claim a two-pronged approach to advocacy: one prong advocating for the legitimacy of the counseling profession, and the other advocating on behalf of the clients and students whom counselors serve (Chang et al., 2012). In our educational experience, SJA on behalf of and in partnership with clients was emphasized, but tangible interventions were not discussed. Further, systemic issues and inequities were often left unaddressed. Thus, we developed this group to more concretely address the second “prong” of advocacy in counseling. First and fourth authors Sunanda M. Sharma and MaryRose Kaplan were part of the executive board of Chi Sigma Mu (Chi Sigma Iota chapter at Montclair State University) and co-founded the social justice committee. Second and third authors Jennifer E. Bianchini and Zeynep L. Cakmak were the first members of the committee who proposed ideas and facilitated events and activities related to social justice that they felt passionately about. Bianchini proposed a social justice book club ahead of a presentation that the CSI chapter organized (hosting the authors of the book Taking Action). The book club met three times with up to three students, from whom we received feedback to help us form the SJA group.
The following semester, fifth author Muninder K. Ahluwalia proposed restructuring the book club into an advocacy group by utilizing the Taking Action text as a framework to teach students about systemic SJA. CACREP (2015) standards state that multiculturalism and social justice must be discussed throughout counseling courses (2.F.2.b.); however, in our experiences, we found that social justice is addressed as an ethical and moral imperative, but curricula do not address concrete SJA skills and strategies to combat systemic oppression. The counseling program in which the first four authors are enrolled and the fifth author is a faculty member offers a social justice counseling class as an elective. However, the class is not consistently offered every semester and has only been taught by that one faculty member. Thus, our aim with this group was to provide a space for our colleagues in which we could collaboratively learn about how to enact social justice. This section will describe the S-Quad model, explain the group structure, outline the proposed learning objectives, and provide a table that outlines the curriculum of the group.
The S-Quad Framework
As a profession, mental health counseling is positioned to “buffer” against challenges with oppression and changes to the status quo (Kivel, 2020). There is an emphasis on intrapsychic interventions to combat systemic issues, rather than attempt to uproot the oppression itself (Kivel, 2020; Ratts, 2009; Toporek, 2018). Toporek (2018) noted that upon reflection of the way the profession is positioned and her privileged identities, she developed a framework through which to take social justice action despite the challenges she continues to encounter. The S-Quad model includes four Ss for social justice advocates to formulate a way to address systemic injustices: strengths, solidarity, strategy, and sustainability (Toporek & Ahluwalia, 2020).
Strengths are described as a combination of one’s existing “skills, knowledge, and expertise” (Toporek & Ahluwalia, 2020, p. 27). Although strengths can be qualities one already has, both personal and professional, the authors also encourage budding advocates to reflect upon strengths that they would like to develop. Solidarity has multiple facets to its definition, as advocates are asked to support, honor, and respect communities they intend to engage with and to also seek support from their personal networks to remain grounded (Toporek & Ahluwalia, 2020). Solidarity is enacted through collaborative efforts and through the lens of cultural humility (Toporek & Ahluwalia, 2020). Strategy is the implementation of strengths and solidarity to construct a plan of action (Toporek & Ahluwalia, 2020). It is important to evaluate the efficacy, efficiency, and impact of different strategic plans to ensure they work toward the stated goal and—most importantly—benefit the community that the action is intended for (Toporek & Ahluwalia, 2020). Finally, a unique facet of the S-Quad model is the fourth “S,” sustainability. Sustainability addresses the wellness of advocates; without it, there is a higher likelihood they may abandon their efforts. SJA can be an enriching and healing practice, but it can also be an emotionally draining pursuit, and one can feel helpless when attempting to combat the gravity and breadth of oppression (Toporek & Ahluwalia, 2020). Thus, the authors encourage budding advocates to take an inventory of the practices that replenish and nourish them in order to remain engaged in their work.
Group Structure
Sharma proposed structuring this SJA group as a biweekly, one-hour, peer-led, open (students were free to join at any point) psychoeducation group, whose grounding framework would be the S-Quad model (Toporek & Ahluwalia, 2020). Due to COVID-19 restrictions, we facilitated the group through Zoom. The objectives of the group were: to describe all components of the S-Quad model, to describe the ethical responsibility of being a social justice advocate, to create a solidarity network of fellow advocates, to increase awareness of how one’s positionality impacts their advocacy work, and to apply the S-Quad model (Toporek, 2018) through the creation of a social justice action plan (Sheely-Moore & Kooyman, 2011). Initially, the intention was to divide each group session into two parts. The first part of the session would be didactic, in which we would discuss the “S” of that week and ground it in a case study. The second half of the session would offer members the chance to process the content so they can apply what they are learning to their social justice plan. Upon reflection and discussion as co-facilitators, we recognized the challenges associated with attempting to address so much content in a 60-minute session and collectively agreed to shift the group and make it akin to a flipped classroom by including pre-recorded didactic videos. This afforded members the chance to view the videos at their own pace and come to the session prepared to engage in dialogue.
In our experiences, instructors who taught our counseling theories courses recommended for us to select one theory to learn about before declaring our theoretical orientation. Similarly, we asked members to narrow down their focus for the purposes of this group to a cause within a community that they feel passionately about. The other structural component we addressed with group members was that this curriculum is cumulative but not necessarily linear; so, an application of the previous “S” is necessary to study the following “S.” For example, once a group member identifies their strengths, we apply those strengths to inform what strategies they will use, but it does not necessarily mean that strengths are not revisited.
Given that this was a psychoeducation group rather than a traditional course, we did not want to use typical didactic methods to engage with this material. We intentionally paired each part of the S-Quad model with a story about an advocate from a minoritized community of whom others likely may not be aware. This demonstrated that SJA is not always done on a public stage. This narrative form of teaching (Hannam et al., 2015) allowed us to contextualize stories of advocates who are quietly resisting oppression in their respective communities. We spotlighted those stories so members could feel less intimidated by the prospect of SJA. In the interest of social justice and accessibility, the Chi Sigma Iota Counseling Honor Society’s Chi Sigma Mu chapter at Montclair State University funded books for interested members so they could follow along with the activities and didactic content. After the second session, we also introduced the idea of the social justice action plan. Table 1 shows the structure/syllabus of the group that we utilized for the semester and describes the ways in which we adapted to agreed-upon changes.
Table 1
Taking Action Group Structure
Week |
Topic & Activity Assigned |
Content/Activities |
Week 1 |
Introducing
Taking Action
S-Quad Model |
• Purpose, rationale, and structure of group
• Group agreements/norms
• Overview of S-Quad model (Toporek & Ahluwalia, 2020)
• ADDRESSING model (Hays, 2022), a framework that explores individual identity in context
• Difference between justice, charity, philanthropy |
Week 2 |
1st S: Strengths
Activity 4.2, p. 29**
|
• Reviewing agreed-upon group norms
• Defining strengths
• Case study: Arunachalam Muruganantham (“The Pad Man”)
Processing case study as a group
• Introducing the social action plan |
Week 3 |
Co-facilitators reflection meeting |
• This session was initially planned to address the 2nd S in the S-Quad, but no members attended the group this day. Instead, as co-facilitators, we met to discuss the progress of the group.
|
Week 4* |
2nd S: Solidarity
Activity 5.1, p. 55 |
• Defining solidarity
• Case study: 4 young Black women, Black Lives Matter protests
Combining strengths and solidarity
Processing case study as a group |
Week 5 |
3rd S:
Strategy
Activity 6.1, p. 66 |
• Defining strategy
• Case study: Cakmak
Strength, solidarity, and strategy
Processing case study as a group
Cakmak’s social action plan |
Week 6 |
4th S:
Sustainability
Activity 7.6, p. 176
|
• Defining sustainability
• Case study: Alexandria Ocasio Cortez
Strength, solidarity, strategy, and sustainability
Processing the importance and guilt of self-care
Processing burnout |
Week 7 |
Final Group
|
• Case study
Apply ADDRESSING, S-Quad model
• Feedback from members |
*Marks shift to videos for the didactic portion
**All activities listed are from Ahluwalia & Toporek (2020).
Reflections
In this section, we offer our reflections on the group and extract salient collective themes that have come about through our processing. In our first session, we informed the group members that we intended to write a reflection paper, and they gave implicit consent to this writing; we did not collect data from group members for the purposes of this article. We begin by grounding the discussion of the group by acknowledging our positionality and social location and how that influenced how we approached our facilitation and planning of the group. Sharma, Bianchini, and Cakmak will provide their most salient takeaways from the forming and facilitation of the Taking Action group.
Positionality
Sharma identifies as a cisgender, South Asian (Indian), middle-class, able-bodied woman who is a doctoral candidate in a CACREP-accredited counseling program and a full-time lecturer in a CACREP-accredited counseling program. I bring a bicultural perspective to my counseling practice and education, and I have attended primarily White institutions (PWIs) for most of my life. As a master’s and doctoral National Board for Certified Counselors Minority Fellowship Program fellow, I learned about the importance and practice of SJA. I am a practicing clinician in private practice (working mostly with White clients), and I engage in advocacy work with South Asian intimate partner violence survivors.
Bianchini identifies as a White, cisgender woman who grew up in a predominantly White community in the United States. My family has lived in the United States for several generations and the majority of my extended family identifies as part of the middle class. I do not have any disabilities and am a practicing Christian. I am a master’s-level graduate student and joined Chi Sigma Iota’s social justice committee in my first semester of coursework.
Cakmak identifies as a Muslim American, cisgender woman of Turkish origin. I do not have any physical disabilities, but I have been diagnosed with general anxiety disorder (GAD) and major depressive disorder (MDD). I identified as part of the upper middle class in Turkey as a child, and I am middle class as an immigrant in the United States. I have two graduate degrees, one in literature and one in counseling. I have done volunteer work with underrepresented religious and cultural communities since I was in high school.
Themes
As cocreators and coauthors, we reflected on our collective and individual experiences of facilitating our Taking Action group. We each completed individual reflection sheets within 48 hours of each group session to capture our takeaways, and we processed our experiences together after each group session. We reviewed our reflection sheets individually and noted themes that arose for each of us. We then collectively reviewed the sheets to determine what themes arose across our reflection sheets. We reengaged in the reflection process as we wrote this manuscript. In this section, we highlight the major themes among our experiences.
Fear
The most significant theme of our collective experience was fear. Throughout each session, fear came up under several different guises, which served as an umbrella for additional themes: judgment, self-efficacy, and humility. Fear was the main antagonist preventing us from doing social justice work before this program. Fear of not knowing the necessary information, fear of saying or doing the wrong thing, and fear of not helping enough or adequately were examples of how this feeling manifested. However, engaging in this group helped us alleviate that fear through resources, support, and a plan of action. In the first session, we felt tentative and timid, and optimistic yet stagnant. After providing members with more information and concrete steps to create real social justice action, our fear dissipated, our passion for working as a group was ignited, and the motivation to take action began.
Judgment
In our first session, when we engaged members in a dialogue about group agreements, we noticed that there was more focus on the importance of the group serving as a judgment-free space than as a confidential one. We felt that members wanted to feel safe in the group because they feared being judged due to their self-perceived incompetence. We recognized they did not want to feel judged by others if their ideas were deemed unacceptable or incorrect. Establishing a nonjudgmental space permitted members to try, even if the outcomes were not as they hoped. We believe it allowed members to have a safe space to begin processing what they understand about SJA.
Judgment was a recurrent theme and shifted from self-judgment to judging others. Members reported feeling frustrated and upset when their peers in the program were not at the same level of advocacy awareness and action as they were. They reported feeling angry about others’ ignorance. Through a shared reflection on these feelings, the group acknowledged that the judgment of others reinforces the barriers to change that we are trying to knock down. Members recognized the importance of being humble regarding other people (another theme discussed below) and empathetic to help manage feelings of judgment.
When discussing sustainability and self-care, members and facilitators shared our hesitations to implement sustainability practices, despite it being an ethical responsibility. This hesitancy revealed itself to be motivated by self-judgment of our productivity levels. It appeared that the group members would not allow themselves the breaks they needed to provide self-care because of the importance they gave to SJA. We then discussed the need to be unapologetic in our self-care as advocates and counselors.
Self-Efficacy
Related to judgment of self and others, we found self-efficacy was another significant and recurrent theme. Almost every group member expressed that they were struggling to feel like they could contribute enough to society to perform real social justice action rather than charity. Having members share similar insecurities resulted in an insightful and vulnerable conversation that helped us to feel connected and inspired. In the second session, members reported experiencing imposter syndrome, likely resulting from their low self-efficacy in social justice work. Our self-efficacy grew throughout the sessions as members received the information and tools they needed to take concrete steps in SJA. Once we clarified a reasonable idea of what was expected of them and had some direction, they felt more prepared to take action.
Humility
Lastly, the theme of humility appeared in several different iterations. The humility through humor with which we, as facilitators, approached this process helped break the ice and create a comfortable atmosphere in our initial meeting. Humility emerged in our second session when discussing the first “S” of the S-Quad model, strengths. In our reflection process, we noted that both facilitators and members appeared to be uncomfortable when sharing what they are “good” at. We, as female-identifying co-facilitators, noted the societal pressure and shame that have historically come with feelings of discomfort for behavior commonly regarded as boastful.
In the fourth session, the group discussed the importance of humility within their community. Members discussed how it was easy to humble oneself when trying to assist a community from the outside, but that it was an important lesson that we must be humble within our own communities. Members seemed to realize that their experience of their community and identity would not be the same as the next person’s, highlighting the importance of intersectionality within the human experience.
Humility was next discussed in the fifth session in terms of failure. Members acknowledged the importance of possessing humility and patience regarding our work because we will generally fail more than we will succeed in our efforts to create change. If we never failed, we would never learn from our mistakes and there would be no more SJA to do. However, knowing this instills the hope to persevere, for you never know what your planted seeds of action will grow into.
Combining Themes
As facilitators, we noticed a parallel between what we were experiencing and our members’ experiences. From the start of our group, we felt we needed to be more qualified to be teachers of SJA. This was our campus’s first peer-led advocacy group, which meant we did not have any models to reference, and we had to rely on our own ideas, skills, and judgment. With faculty support, we went outside the confines of our curriculum because we wanted to share and engage with this content in a meaningful way. This was a large undertaking, with little training and even less confidence. Similar to what we observed in our members, we were afraid of making mistakes in the content, direction, and discussion of this group because of the weight of the topic of social justice—especially as the first group any of us attempted to create or lead. We had to adapt to constantly developing circumstances, and this felt inappropriate for us as leaders. Something we recognized much later was that we could teach and learn simultaneously; we did not need to reach a point of expertise before developing this group. Although we do not consider ourselves experts in SJA, the work we did to prepare for each session, combined with the humility with which we presented ourselves and our work, effectively allowed us to lead the group to the best of our ability.
Another source of our fear was that there was an ulterior motivation for creating this group, which was not purely social justice–oriented. We sought a sense of community, particularly given the isolating COVID-19 pandemic we were living through, and running this group gave us that community, support, and friendship. This longing for connection played into our feelings of being unqualified to do social justice work because a few of us became involved in this project out of a desire to work with friends, and not solely because we wanted to devote ourselves to social justice. However, this search for connection and participation in this SJA group gave us a passion for this work if it was not present beforehand. That feeling of connection and belonging provided us with the inner power to attempt something bigger than ourselves. The bond we authors created while facilitating this group instilled the importance of collaboration, especially when doing something new, significant, and daunting. The “S” for solidarity was also particularly salient in this case; we recognize that we could not have created or run this group alone. We needed each other to not only complete all the work required but also to hold each other accountable, support each other in times of need, and encourage each other to keep going even when our hopes dimmed. In a sense, this group and the connection to each other provided the “S” for sustainability and wellness for ourselves and our work.
While reflecting on these two sources of our fear as facilitators, we discovered our desire to make this call to the counseling profession: to strengthen the bridge between academia and counseling in practice. Applying the knowledge gained from our courses to daily practice could be less intimidating and feel more like the natural progression of our nascent counseling careers. However, once the opportunity arose to test our skills, we felt hesitant and unprepared. Creating an advocacy group is not the only venue in which this fear of practice appears. As students, we authors felt a similar fear when stepping into our practicum and internship sites. It is natural to feel afraid when seeing clients for the first time as CITs, but this fear could be lessened by academic leaders guiding students into the field before their final year of studies. If more opportunities to work with real issues affecting communities were available to students and supported by faculty, the transition between the classroom and fieldwork would feel less daunting.
Discussion
Although this project was not an empirical study, our reflective process taught us about how it feels to learn about SJA and the labor required to teach about SJA. With this knowledge, we have identified potential implications for the counseling profession and counselor education training programs. We also acknowledge the limitations of the group we formed and facilitated.
Implications
Per our experience, we believe social justice counseling—and advocacy skills more specifically—must have a more prominent place in counseling curricula. Potential solutions may include consistently operationalizing social justice counseling and SJA in counselor training programs (CSJ, 2020). Furthermore, it is imperative to have more guidance from our institutional standards such as CACREP (2023) and to have more ethical standards regarding SJA in the next iteration of the ACA Code of Ethics. CACREP (2023) requirements establish content that should be covered throughout all coursework, rather than specific classes; however, each program might have a different approach to operationalize these standards because they are vaguely defined (Austin & Austin, 2020). For example, in the current CACREP (2023) standards, there is more frequent mention of social justice compared to the 2016 CACREP standards; however, there is still ambiguity about how this may present in a counseling course. Standard 3.B.1 (CACREP, 2023) says that counseling curricula must state how “theories and models of multicultural counseling, social justice, and advocacy” are addressed, but there is no mention of techniques, interventions, or skills for SJA. As a point of comparison, there are specific guidelines with respect to content like group counseling which delineate time that students must spend engaged in direct experience. However, it appears that social justice and SJA are still referred to in broader terms with fewer contingencies about how they must be addressed. We recognize that out-of-class work like advocacy might be left out of the curriculum because there are many required courses and training standards filling up students’ time in graduate school (Vera & Speight, 2003). However, we urge counseling leaders to consider the importance of SJA and the core role it plays in our healing work and our counseling identity.
Limitations and Future Directions
This group was developed and facilitated to encourage counseling students to develop their social justice advocate identity, but it was not an empirical study, and our collective reflections can only offer so much insight to facilitating such groups in the future. As this was an extracurricular group for which attendees took time out of their personal schedules, we do not know what motivated our peers to attend sessions that we offered. This would be important knowledge to address in future offerings of this group and to understand students’ attitudes toward social justice in counseling. Another limitation of our group was our inability to reach students who are unsure of what social justice is and might not recognize it as an inherent and imperative part of mental health counseling. Practicum and other service-learning opportunities for SJA within the profession have been explored in the literature (Farrell et al., 2020; Field et al., 2019; Langellier et al., 2020), but perhaps peer encouragement can help CITs to feel more confident as advocates. Although we intentionally kept the group open for accessibility, new introductions and catching up took time away from the group plan and content. We do not have data to explicate a group like this, but we hope our master’s and doctoral peers feel encouraged to start similar groups within their own programs. Finally, we wrote this article more than a year after our group ended; although we relied on our reflection sheets and notes from our experience, we are aware that there may be gaps in our recollections.
For future groups, we would be interested to complete an empirical study through an IRB in order to collect data regarding peer-led SJA groups. Screening or surveys before and after the group could not only provide valuable data, but also offer guidance for attendees even before the group starts and an opportunity for reflection after the group ends. Our decision to keep our group open led to attrition of members; thus, empirical studies might also investigate factors that contribute to student engagement. Collecting quantitative and qualitative data may provide further insight into effective strategies for describing and encouraging students to engage in concrete SJA skill development.
Conclusion
The experience of facilitating an SJA group was new, challenging, transformative, and important to our growth as CITs and budding counselor educators. As counselors, we understand our ethical duty to engage in SJA; however, we have not had adequate training in tangible strategies to utilize when advocating on behalf of our clients. The S-Quad model is an important guide that helped facilitate our understanding of how to implement SJA as mental health professionals. As co-facilitators and coauthors, we learned a great deal about ourselves as developing social justice advocates, CEs, and CITs and confronted fears parallel to those of the group members. Although SJA is a growing focus in the counseling literature, there is a great deal of research and training that must continue to occur so current and future counselors can develop their social justice advocate identities.
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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Sunanda M. Sharma, MS, NCC, LPC (NJ), LPCC (OH), is a lecturer at Wright State University. Jennifer E. Bianchini, BFA, is a master’s student at Montclair State University. Zeynep L. Cakmak, MA, LAC (NJ), is a mental health counselor at Montclair State University. MaryRose Kaplan, PhD, NCC, LPC, is a school counselor and adjunct professor at Montclair State University. Muninder K. Ahluwalia, PhD, is a professor at Montclair State University. Correspondence may be addressed to Sunanda M. Sharma, 3640 Colonel Glenn Hwy., Millett Hall 370, Dayton, OH 45435, sharmas1@montclair.edu.
Jan 17, 2024 | Volume 13 - Issue 4
K. Lynn Pierce
Persistent ableism in higher education, counseling practice, and society necessitates disability justice advocacy. In this article, the author explores the historical context of disability and the importance of disability knowledge for counselors and counselor educators. In addition to discrimination and inaccessibility, able privilege and lack of representation present significant barriers to equity and empowerment of disabled people. Better awareness of disability culture and community-oriented frameworks for the collective liberation of disabled people, such as disability justice, can improve disability equity and allyship within counseling and counselor education.
Keywords: ableism, disability justice, advocacy, allyship, counseling
The disability rights motto, “Nothing about us without us,” highlights the importance of including disabled people in decisions that affect them. However, in a society dominated by able privilege, this motto has at times translated into “Nothing at all.” The absence of disabled representation and empowerment leads to a lack of understanding, empathy, and action toward improving the lived experiences of the disability community.
Over 60 million Americans live with a disability, making them the largest minority group in the United States (Centers for Disease Control and Prevention, 2023). The Americans with Disabilities Act (ADA) defines a person with a disability as “a person who has a physical or mental impairment that substantially limits one or more major life activity” (ADA National Network, 2024, para. 1). These activities include daily tasks like breathing, walking, talking, hearing, seeing, sleeping, taking care of oneself, doing manual tasks, and working. The year 2020 marked the 30th anniversary of the ADA, the major law granting protections to disabled individuals. Yet institutional ableism continues to persist in higher education, counseling practice, and public life. Disabled people face various obstacles, including unresolved barriers to physical access (including of health care and mental health services), social stigma, and insufficient funding for rehabilitation programs. Able privilege (also referred to as ability privilege or able-bodied privilege) is a viewpoint in which non-disabled bodies are considered normative (Lewis, 2022). Able privilege is pervasive in society and continues to contribute to societal stigmatization of and discrimination against disabled bodies, minds, and lives.
Positionality
The positionality of authors engaged in disability justice work is crucial for acknowledging biases and perspectives that influence the writing process. This practice also allows for transparency for readers to better understand the context this article is situated in. This is particularly important given the diversity of cultural norms within and between disability subcommunities and the differences of perception of ableism, access, and disability equity shaped by individuals’ unique experiences of disability.
I identify as a White, queer, disabled academic who aligns with crip culture. The term “crip” is a reclamation of the derogatory slang “cripple,” much as “queer” has been reclaimed by the LGBTQ+ community. I integrate the principles of disability justice and bring lived experience into advocacy, clinical, and research work pertaining to the disability community. I have navigated ableism personally and professionally and am invested in critical examination of ableist systems and advancement of cross-disability liberation. I use an anti-ableist and identity-affirming ideological lens to approach disability advocacy. The use of identity-first language throughout this paper reflects this positionality and is an acknowledgement of many disability subcommunities’ preference for this language.
A Brief History of Disability in the United States
Attitudes and policies surrounding the disability experience in the United States have historically imposed harsh restrictions and exclusions grounded in ableism. In the late 19th and early 20th centuries, the eugenics movement promoted the view that disability was undesirable and needed to be purged from society (Rutherford, 2022). Many proponents of eugenics were scientists, doctors, and policymakers. This contributed to forced sterilization and institutionalization of disabled people, restrictive immigration policies, and segregation in education. These policies, along with social stigma, led to disabled people being socially and economically disadvantaged and pushed to the fringes of society (RespectAbility, 2021).
In the 1970s, The Independent Living Movement and Centers for Independent Living (CILs) emerged as a civil rights campaign spearheaded by and for the disability community (Hayman, 2019). This movement pushed back against the discriminatory environments and paternalistic professionals of the time and focused on providing peer support, dignity, civil rights, and autonomy through direct service and advocacy. At this same time, the 504 protests (referring to section 504 of the Rehabilitation Act) paved the way for the civil rights work that eventually culminated in the passage of the ADA in 1990, which finally extended similar federally protected rights to disability as those that cover race and gender (Cone, n.d.).
Since 2000, disability-related activism has been most prominent online. Within this environment, community-based efforts such as the #SayTheWord movement and disability-related hashtags began to trend on social media. Many within the disability community have embraced X, formerly known as Twitter, specifically because it is free, has accessibility features, and allows for global connection and unprecedented reach to businesses and public figures, as well as other individuals and organizations within the disability community (Wilson-Beattie, 2018). Facebook and other social media groups have been important gathering places for disabled individuals to connect, obtain information about their conditions and available treatments, and find others who can relate to their experiences.
Exclusion of Disability in Education and Practice
The Rehabilitation Act of 1973 and the ADA both extended disability protections into higher education settings. However, because of the lack of protections in these settings prior to these laws, colleges and universities were already built on inaccessible foundations both physically and socially (Dolmage, 2017). This has led to a continued lack of equity for disabled people within higher education.
The National Center for Education Statistics (2018) reported that 19.4% of the undergraduate student body report having a disability, but only 11.9% at the graduate level. The Center for College Students with Disabilities reported that less than 4% of faculty members have disabilities (Grigely, 2017).
This suggests barriers to recruitment and retention and/or biases that prevent disclosure of disability identity. Despite the requirements under the Rehabilitation Act and ADA to provide equitable access, providing disability-related supports is often in conflict with ableist systems within higher education. For example, very few universities and colleges embrace a holistic and affirming model to support disability inclusion on their campuses and instead use an accommodation-only–focused approach. Most colleges and universities do not have a disability cultural center or student organizations focused on disability, despite the benefits for students and the community that such a center can provide (Elmore et al., 2018).
Disability and Counselor Education
Unfortunately, there is very little research available on disability within counseling and counselor education. Disability is often absent from captured demographics in our research, including when studies focus on the experiences of diverse counselors, counselor educators, and students. There is no information currently available regarding disability representation among counselor educators or counseling leadership, and very little about the experiences of disabled individuals within the profession or even the experiences of disabled clients with professional counselors.
Counselor education programs, apart from rehabilitation-specific classes, seldom focus on disability topics. According to Feather and Carlson (2019), 36% of faculty surveyed believed their program was ineffective at addressing disability topics, while only 10.6% believed their program to be “very effective” in this content area. Faculty self-assessment of competence to teach disability-related content correlated significantly with previous work or personal experience with disability, underscoring the importance of exposure to and training about disability-related concepts being infused across core areas. Key elements related to disability competence such as accessibility, able privilege, disability culture, and disability justice are explored in the following sections.
Considering Accessibility
Accessibility is a word that is often co-opted in diversity, equity, and inclusion (DEI) spaces to mean attainability, affordability, inclusion, etc. However, accessibility is a concept that is legally related to the ability of disabled people to equitably interact with built environments and services. The Office for Civil Rights (OCR) defines accessibility as:
When a person with a disability is afforded the opportunity to acquire the same information, engage in the same interactions, and enjoy the same services as a person without a disability in an equally integrated and equally effective manner, with substantially equivalent ease of use. (U.S. Department of Education, 2013, p. 3)
Physical accessibility includes factors such as ample accessible parking, pathways without stairs, clear curb cuts, even paving, wide doors and pathways, clear signage, clear spaces for wheelchairs and mobility devices, and accessible bathrooms. Accessibility of websites and other digital services is also covered under the ADA. The accessibility of learning management systems, captioning and transcripts for videos, and accessible file types are all important factors in classroom accessibility. Despite the ADA requirements, many spaces fall short, emphasizing the need for continual self-evaluation and consultation (ADA National Network, 2016).
Accessibility is often viewed only as what must be done at a minimum legally, and sometimes it is unclear within a given structure who exactly is responsible for ensuring accessibility. This often results in a reactive approach that places the burden on disabled people to experience barriers and report them. Another common approach is an accommodation mindset, in which disability is seen as so unlikely within a setting that those who need disability supports are seen as burdensome and must request them in advance. This can be contrasted with a barrier reduction or universally designed approach, in which disability would be proactively considered and planned for within a system or space. The resistance to these more equitable approaches is largely the result of lack of awareness of disability prevalence and needs, rooted in ableism and able privilege (Dolmage, 2017).
Able Privilege
Able privilege (also referred to as ability privilege or able-bodied privilege) is a viewpoint in which non-disabled bodies are considered normative. This condition lends itself to the continuation of inaccessible environments and attitudes, which, in turn, further entrenches able privilege within society. To illustrate the implications of able privilege, one may consider the day-to-day experiences of non-disabled individuals and the stark contrast with the experiences of disabled people. The simple act of opening a door without strategizing your approach or having the liberty to choose any seat at a movie theater or concert are further indicators of able privilege. If you have always been able to access materials showcasing individuals of your ability as role models or had access to mentors who mirror your ability, you have experienced able privilege. The ability to move around with the assurance that housing options will generally be accessible to you is a distinct advantage, one that disabled people, particularly those who use mobility devices or who have physical limitations often cannot take for granted. The invisibility of these privileges to those who benefit from them is precisely what fuels the cycle of able privilege, leading to a lack of representation and empowerment for disabled individuals (Dolmage, 2017).
Able privilege is a major but often neglected aspect of social inequality, mostly because disabled individuals are systematically underrepresented. This exclusion is deeply ingrained in our society, impacting policies, cultural norms, and current structures, which further magnify able privilege. “Ugly laws,” a discriminatory legislation active in certain parts of the United States through the ’70s and ’80s, literally pushed disabled people out of public view, further contributing to their erasure (Schweik, 2011). The discomfort with the disabled body being seen and acknowledged in public continues, with organizations like the Ford Foundation finding a lack of disability representation in popular media (Heumann et al., 2019). Despite increasing emphasis on diversity, equity, inclusion, and accessibility (DEIA) in counseling, the reality is that the disability community often finds itself on the outskirts of these crucial conversations because of historical inequalities that are unchallenged or a continued lack of equitable access (Dolmage, 2017).
This cycle of exclusion parallels a common physical accessibility challenge: The lack of disabled people present in a space is often used to justify a lack of priority given to accessibility. However, the inaccessibility itself is the barrier preventing disabled people from entering and remaining in these spaces in the first place. Inaccessibility precludes disabled presence and advocacy, and barriers often then stand unchallenged.
Our educational systems and programs are no exception to the impacts of the exclusion of disabled bodies and minds. Ableist ideologies are often left unchallenged and unknowingly promoted, shaping the understanding of disability at crucial developmental stages. The exposure that most people have to disabilities is also skewed, leading to the formation of harmful stereotypes and stigmas discussed further below.
Disability Culture
Disability culture encompasses a group identity with shared experiences, a history of oppression, literature, art, language, and expression. This is highlighted through various forms of art and literature and through movements advocating for disability rights and inclusion (Brown, 2015). However, the disability community boasts a rich and diverse culture that’s often absent from mainstream media and popular culture.
Representation
As with other minoritized and marginalized populations, the representation of disability in mainstream media, film, and literature can have significant impacts on the societal view of disability and bias and stigma experienced by disabled individuals. Because of the various challenges in access presented by society and the taboos regarding discussions of disability, media is a primary way many people may form opinions about disability and disabled people. Unfortunately, these depictions are few and often convey misinformation and harmful tropes. In a review of 100 top movies in 2016, fewer than 3% of characters had a disability (Smith et al., 2017). Heumann and colleagues (2019) found in their examination of disability in media that most disabled characters in film fell into four stereotypes: the Super Crips who triumph over disability and provide the message that disability is merely a negative thing to be overcome; Villains who are often portrayed with disfigurement of some kind and play on fear and discomfort of disability and difference; Victims who are defined only by their disability and often are shown as better off dead than disabled; or Innocent Fools who embody negative stereotypes of those with intellectual disabilities or neurological differences. These issues with one-dimensional and negative representation in the small number of examples of disability shown on the screen are compounded by a lack of input from disabled writers, actors, or directors. Most disabled characters are played by non-disabled actors, and disability is the most underrepresented minority in the Hollywood film industry (Woodburn & Kopić, 2016).
Within the disability community, a starkly different narrative emerges, often directly hitting back at the misrepresentation and villainization of disability that is commonplace in mainstream media. For example, Disfigured: On Fairy Tales, Disability, and Making Space by Amanda Leduc (2020) critically analyzes the narratives ingrained in our culture around disability. Leduc particularly explores the impact of fairy tales and their modern retellings on identity development and belonging for disabled people, centering her own story and other disabled people’s narratives. Crip Camp, a Netflix documentary, discusses the disability rights movement through the personal stories of advocates such as the late Judy Heumann (Hale & LeBrecht, 2020). Heumann’s autobiography, Being Heumann: An Unrepentant Memoir of a Disability Rights Activist (2020), is a powerful work in the disability space along with early commentaries on empowered language and identity choice such as Nancy Mairs’s essay, On Being a Cripple (1986).
“Crip culture” is one notable aspect of disability culture. In the anthology Criptiques, compiled by Caitlin Wood (2014), crip, slang for cripple, is embraced as a powerful self-descriptor, representing audacity, noncompliance, and a direct challenge to disability being pushed into the shadows. It is an example of the arts and expression of “crip culture,” which draws on shared experiences of ableism, creating a community that affirms and reflects its members’ originality and beauty. Criptiques presents a diverse set of essays embodying this revolutionary spirit and fostering discussions about disability experiences (Wood, 2014).
Social media platforms, particularly X/Twitter, have catalyzed the formation of a global disability community. Hashtags like #DisabledandCute and #AbledsAreWeird have trended, fostering discussions and highlighting the shared experiences within the disability community. “The disability revolution will be tweeted” because of the critical role social media plays in fostering community in accessible formats (Wilson-Beattie, 2018).
Emerging trends in disability spaces include the #SayTheWord movement, which seeks to reclaim the term disability and challenges forced person-first, euphemistic language often pressed on the disability community by able-bodied individuals, discussed further below. Spoonie communities are also prevalent in chronic illness and even some mental health circles. These spaces use the spoon theory by Christine Miserandino (2003), which describes how there is a set amount of energy for daily tasks that can be lowered by disability-related factors such as pain or fatigue. Spoon theory seeks to help disabled people and those close to them understand the fluctuating nature of chronic illness and better communicate about it.
Language and Empowered Expression
It is essential to understand how to talk about disabilities and disabled people in an empowering and inclusive way. Person-first language (e.g., “person with a disability” and “person with [condition]”) emphasizes the person before the disability. While this language is used primarily in academic spaces and was mandatory until the seventh edition of the American Psychological Association style manual (APA; 2020), it is often criticized for being avoidant and contributing to perpetuating rather than confronting stigma (Collier, 2012).
Alternatively, identity-first language proposes that the identity of an individual should lead the conversation. This mode of language is used more commonly within disability spaces, such as “disabled individuals” or “autistic people.” Some subgroups, like the Deaf and autistic communities, strongly identify with their disability factors, promoting a sense of disability pride.
Disabling language, such as “handicapped,” “wheelchair-bound,” or “crippled,” are terms that are outdated, inaccurate, and offensive. These terms can be stigmatizing based on social and historical contexts, like referring to someone diagnosed with schizophrenia as “schizophrenic.” The exception to this is in usages such as those outlined above in which some subcommunities have reclaimed words like “crippled” or find them accurate and therefore identity affirming. This highlights a trend that language and slang within the disability community often focuses on relevant factors of assistive technology or the disabilities themselves (e.g., “wheelies” for wheelchair users, “spoonies” for those who endorse spoon theory, or “potsies” for those with postural orthostatic tachycardic syndrome [POTS]), whereas out-of-group language typically rejected by disabled people is often designed to avoid using the word disability (e.g., “differently abled,” “diverse-ability,” or “special needs”).
While person-first language is valid and should be used when it is the preference of the individual with a disability, there are many compelling arguments for normalizing and empowering identity-based language. Person-first language can be incongruent with people’s self-concept and with their experience of the perception others have of them. Person-first language can perpetuate stigmatization of disability, leading to perceived hypocrisy (Collier, 2012). The language choices made by able-bodied allies often disregard the preferences of the disabled community, echoing a history of erasure and opposing the principle of “nothing about us without us.” This has sometimes extended to able-bodied academics imposing their preference for person-first language on disabled people through academic standards and publishing norms. It can be argued that these restrictions historically have inhibited self-identification, language preference, and the ability to produce scholarship that accurately represents disabled people and community values. This impedes collaborative research with the disability community and reinforces a division and lack of understanding between the disability community and counselors or other medical and mental health providers.
Allyship and Disability Justice
Allyship is not an identity but a practice. Allies for the disability community must operate in solidarity with and advocate for the rights of those oppressed by systems in ways that do not reinforce the system’s oppression (Brown, 2015). This involves actively listening, observing dynamics of power, focusing on impact rather than intent, leaning into discomfort, modeling inclusive language, and offering kind and constructive feedback. In this context, it’s vital to understand ableism, defined as, “a system of assigning value to people’s bodies and minds based on societally constructed ideas of normalcy, productivity, desirability, intelligence, excellence, and fitness” (Lewis, 2022, para. 4). Ableism devalues and discriminates against disabled people and gives preference and normative status to able-bodied people.
The Disability Justice framework (Sins Invalid, 2015) offers a comprehensive and inclusive perspective on human bodies and experiences. The Disability Justice framework was originally developed by the activist Patty Berne, a co-founder of the organization Sins Invalid, to reflect the collaborative work occurring in community spaces. Sins Invalid is a performance project that deconstructs the dehumanizing practices disabled people face and centers intersectionality and diversity of identities.
The Disability Justice framework emphasizes that every body is unique, important, and powerful. This framework understands that people are shaped by complex intersections of factors like ability, race, gender, sexuality, social class, nationality, religion, and more. Instead of isolating these factors, it insists on viewing them collectively. This viewpoint stresses that our pursuit of a fair society is rooted in these intertwined identities and points out a critical observation: Our current global system is essentially “incompatible with life” (Berne, 2015, para. 13). Disability Justice principles include “leadership of the most impacted,” “interdependence,” “collective access,” “cross-disability solidarity,” and “collective liberation” and focus strongly on intersectionality and cross-movement organizing to ensure no one is left behind or excluded (Sins Invalid, 2015, p. 1).
Although there are voices advocating for disability rights, these are predominantly from within the disability community itself, a testament to the lack of understanding and allyship from broader society. Historically, those who could have been allies—abled caregivers, academics, medical professionals, and others—have often worked against the community, whether consciously or not (Dolmage, 2017). This can be combated first by ensuring access to spaces so that disabled voices are present. Then, allies can elevate these voices while implementing a framework like disability justice to ensure that those impacted are leading and that cross-disability approaches are being implemented around equity and liberation work, in line with community priorities.
Implications for the Counseling Profession
Counselor Education and Preparation
Instructors have a critical role in supporting disabled counselors-in-training. Not only is this support mandated by law, but it also increases visibility, representation, and lived experiences of disability in the profession, thereby improving services for clients. Implementing Universal Design for Learning (UDL) can minimize the need for accommodations and provide access, engagement, and learning motivation to the widest possible audience of learners (CAST, 2018). UDL is grounded in Universal Design principles, which are architectural strategies to make physical spaces usable by the widest number of people possible. The UDL principles include strategies such as multiple means of representing information to capture various learning types and multiple means of expression to allow learners to demonstrate learning in various ways (CAST, 2018). Adopting these principles can significantly contribute to making materials and learning environments more accessible. Instructors should consider how they can better focus on curriculum, activities, and assessments that increase exposure of counseling students to disability as a common multicultural factor and client identity. In addition, it is highly advisable to approach accessibility proactively in assignments and course materials and to become comfortable with the process required to swiftly provide equitable accommodations for students when a request is made.
Where a need for access or accommodations is established for a student, an opportunity also exists to proactively advocate for and support students in ensuring accessibility and equity in their practicum and internship placements, graduate assistantships, and other duties required for or connected to their program of study. Sometimes a student’s disability and related accommodation needs are new. Even for those who have established what they need to succeed in a classroom, counseling programs with their clinical requirements are a new setting and students may not always know what they need in advance. It is therefore the responsibility of counselor educators to take a barrier reduction approach, take on the labor of researching the accessibility of approved sites and processes of accommodations specific to graduate students within their universities, and work collaboratively with the student at all stages of a program.
Counseling Practice
It is an ethical mandate that counselors become competent in working with disabled clients as addressed in the ACA Code of Ethics pertaining to nondiscrimination and multicultural issues (American Counseling Association, 2014). It is also important for counselors to work in ways that are respectful and promote client autonomy. This can begin with ensuring that proper etiquette is understood. Examples include speaking directly to a person, not their interpreter or attendant; not drawing attention to, commenting on, or interfering with assistive technology (including service animals); and asking questions rather than making assumptions. Working from a disability-affirming perspective is important, as well as being engaged in self-reflective work around disability bias and seeking appropriate supervision. Supervision might be with a peer to check for bias and process reactions to disability topics, or with someone with disability identity or rehabilitation training to consult on best practices around accessibility and disability-affirming approaches.
The physical counseling environment needs to be accessible according to ADA guidelines, and this should be determined based on the checklist for existing facilities and/or a professional consultant (ADA National Network, 2016). Continuing to offer telehealth as an option while still ensuring spaces are accessible helps to meet a long-standing need expressed by disabled people in ensuring access to mental health care. Websites need to meet web accessibility guidelines, and it is advisable to ensure accessible formats are available for documentation (e.g., large font and digital options). Within spaces, common triggers for various conditions should be considered. For example, fluorescent lights may trigger migraines or neurological conditions, while chemical sensitivities could be triggered by anything from bleach and other cleaning supplies to perfume, room fresheners, or lavender and other essential oils.
In working with clients, it should not be assumed a client is not disabled merely because they are not visibly disabled or have not disclosed a disability. If a client is visibly disabled or has disclosed but not elaborated, signaling openness to further discussion while respecting boundaries and client priorities is warranted. Intrusive questioning is never appropriate, and client autonomy and treatment goals should always be respected. In my own work, I think of this similarly to when I may diffuse a question regarding trauma on an intake by acknowledging the client may not yet trust me; we can come back to discuss it further at any time in our work together, and I invite them to share to their level of comfort. An example of broaching a visible or previously disclosed disability might be simply asking if there is anything that can be done to increase accessibility or comfort in the space. Another approach might be to reflect the client’s own language to describe the disability, chronic illness, assistive technology, etc. and to simply ask if there is anything specific that the client would like for you to know up front that would support your work together, or whether they would like to address things as they come up.
Conclusion
Disability culture is rich and complex, asserting its place in sharp contrast to mainstream narratives with defiance. It is a culture that celebrates wholeness and intersectionality and challenges ableist norms without apology for occupying space.
By understanding how ableism in counseling and counselor education fits into the broader history of disability oppression and increasing awareness of disability culture and disability justice, the counseling profession can better serve the disability community. Normalizing conversation about disability allows us to prepare ourselves, our students, and our supervisees to work with this large and diverse population. When we act intentionally to proactively make spaces accessible, we are providing disabled people with the same rights we provide to other clients. This allows them to share their stories gradually and comfortably, without having to disclose too early or fight for their basic rights.
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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K. Lynn Pierce, PhD, NCC, ACS, LPC, CRC, is an assistant professor and Counselor Education and Supervision PhD Program Coordinator at Mercer University. Correspondence may be addressed to K. Lynn Pierce, Mercer University College of Professional Advancement, 2930 Flowers Rd. S., Chamblee, GA 30341, pierce_k03@mercer.edu.