Vanessa Kent, Helen Runyan, David Savinsky, Jasmine Knight
When the pursuit of doctoral studies and motherhood intersect, the risk of attrition increases. Although other studies have explored the challenges of student mothers in academia, this study looked at how mentorship might mediate them. This phenomenological study examined the mentoring experiences of doctoral student mothers or recent graduates in counselor education and supervision programs (N = 12). Unanimously, participants articulated that their professional identity was enhanced by their identity as mothers, but balancing multiple roles required supportive mentors. Participants described the personal qualities of effective faculty and peer mentors, many also mothers who understood their needs. Mentoring served as a protective factor in helping navigate barriers, providing academic and emotional encouragement, reducing isolation, and creating realistic timelines. Suggestions for mentoring programs and advocacy are discussed.
Keywords: mentoring, doctoral student mothers, counselor education, phenomenology, advocacy
Over the past decade, surveys have indicated incoming doctoral students are less traditional than previous generations (National Center for Science and Engineering Statistics [NCSES], 2017; Offerman, 2011). These students (e.g., women, minorities, and international students) may experience cultural maladjustment while attending traditionally structured academic institutions (Holley & Caldwell, 2012; Ku et al., 2008; NCSES, 2017). This may lead to dissatisfaction, isolation, and subsequent attrition (Holley & Caldwell, 2012; Ku et al., 2008; NCSES, 2017; Offerman, 2011; Stimpson & Filer, 2011).
Focusing on women, the number earning doctoral degrees has steadily increased over the past 20 years (NCSES, 2017). Percentages reached a record high in 2008–2009 as women earned slightly over 50% of all doctoral degrees, except in male-dominated fields, including engineering, mathematics, and physical science (Miller & Wai, 2015; NCSES, 2015). Furthermore, with a ratio of six females to one male completing bachelor’s and master’s degree programs yearly, the majority of those entering the doctoral pipeline are expected to be female (Miller & Wai, 2015). These incoming female doctoral students are likely to be in their prime childbearing years, in dual-income households if married, and caring for dependents (Lester, 2013; Offerman, 2011; Stimpson & Filer, 2011). Finding ways to assist these doctoral student mothers in completing a doctorate requires further investigation.
Although earning a degree in higher education can bring personal satisfaction, higher professional status, and economic gains, the process can also result in unforeseen stress and challenges to work–life balance, leading to dissatisfaction and attrition (Brus, 2006; Lynch, 2008; Martinez et al., 2013; Offerman, 2011; Stimpson & Filer, 2011). Despite the rigorous selection process, attrition rates for doctoral students hover between 40%–60% (Council of Graduate Schools, 2010). Beyond academics, extenuating factors that contribute to the attrition of doctoral students include stress; financial hardship; commitment conflicts; unexpected life interruptions; mental and physical health issues; and changes in the family structure, including having children (Brus, 2006; Lynch, 2008; Martinez et al., 2013). When the doctoral student is a new mother or the primary caregiver, these factors become exacerbated (Brus, 2006; Holm et al., 2015; Lester, 2013; Lynch, 2008; Stimpson & Filer, 2011). Because of the structural design of higher education and cultural pressures of motherhood that seem at odds with each other, graduate student mothers are at higher risk of attrition than almost any other American academic group (Lester, 2013; Lynch, 2008).
Challenges Facing Doctoral Student Mothers
The challenges of student mothers navigating the competing roles of academic scholar and primary caretaker are well documented (Holm et al., 2015; Lester, 2013; Lynch, 2008; Pierce & Herlihy, 2013; Trepal et al., 2014). Mothers pursuing doctoral degrees may find balancing academics and employment a daily challenge, compounded by the second shift of childcare and housework (Lynch, 2008; Pierce & Herlihy, 2013; Stimpson & Filer, 2011). Despite movement toward an egalitarian view of child-rearing among contemporary couples, the burden of overseeing the household duties and childcare remain largely the mother’s responsibility (Lester, 2013; Medina & Magnuson, 2009; Misra et al., 2012). Student mothers juggling multiple roles report dissatisfaction in their work–life balance because of time and scheduling demands, as well as hindrances in the workplace and higher education (Brus, 2006; Holm et al., 2015; Lynch, 2008; Trepal et al., 2014). Research on support for this vulnerable population points to faculty and peer support as possible mitigating factors to attrition and dissatisfaction (Bruce, 1995; Holm et al., 2015; Trepal et al., 2014).
Mentoring Relationships That Mitigate Attrition
Research spanning almost two decades correlated strong advisor and mentor relationships with successful student outcomes (Bruce, 1995; Clark et al., 2000; Holley & Caldwell, 2012; Patton & Harper, 2003). Mentoring has been especially important for underrepresented populations such as international students; students of color; first-generation college graduates; women in science, technology, engineering, and mathematics (STEM) disciplines; and female students/faculty who were also mothers (Brown et al., 1999; Holm et al., 2015; Kendricks et al., 2013; Ku et al., 2008). A mentor is a person who provides professional and personal support to assist the less skilled mentee in becoming a full member of a particular profession (Brown et al., 1999; Clark et al., 2000). This study focuses on academic mentors, both formal and informal. Formal mentoring involves a faculty member, formally assigned to or requested by the student, whose roles may include but also extend well beyond that of an advisor, dissertation committee member, supervisor, or instructor (Hayes & Koro-Ljungberg, 2011; Patton & Harper, 2003). Informal mentoring can be categorized by who provides the mentoring: faculty or a peer. Informal faculty mentoring occurs as a faculty member organically connects with a student on common interests to provide support, often around motherhood, suggesting the importance of access to a faculty member who is also a mother (Hermann et al., 2014; Holm et al., 2015; Trepal et al., 2014). Peer mentoring provides that connection through an informal relationship between a more senior doctoral student and a junior doctoral student (Noonan et al., 2007). Peer mentoring may occur as part of a structured program, but it more often occurs organically as upperclassmen fill this need through joint interests, scholarly activities, or motherhood (Lynch, 2008; Noonan et al., 2007).
Shifting from a traditional hierarchical model, relational mentoring encompasses not only the advising relationship to promote career and professional development but also the genuine empathic relationship that emerges from a reciprocal, collaborative approach (Gammel & Rutstein-Riley, 2016; Kelch-Oliver et al., 2013). Results are greater accessibility to the mentor, opportunities to share knowledge in research and publishing, extended support to students, knowing students on a more personal level, fostering friendships, and building community (Brown et al., 1999; Bruce, 1995; Hadjioannou et al., 2007; Hayes & Koro-Ljungberg, 2011). Benefits of relational mentoring include mutual growth opportunities for both the mentor and mentee, greater academic achievement, personal satisfaction, and increased social and emotional support (Gammel & Rutstein-Riley, 2016; Kelch-Oliver et al., 2013).
Connections with other student mothers is an important support mechanism, reducing isolation with increased social support (Hermann et al., 2014; Lynch, 2008; Patton & Harper, 2003; Trepal et al., 2014). Chief factors influencing female doctoral students’ satisfaction in their programs were female faculty and peers serving in supportive/mentoring roles, sharing resources (such as childcare), addressing stress, and encouraging healthy choices around family life (Bruce, 1995; Brus, 2006; Holm et al., 2015; Trepal et al., 2014). Studies specific to African American women in psychology found that same race/gender mentorship was imperative in recruitment, retention, and training of this population (Kelch-Oliver et al., 2013; Patton, 2009).
Female mentorship may be an untapped resource in counselor education and supervision (CES), as there is little research exploring the mentoring of doctoral student mothers (Bruce, 1995; Holm et al., 2015; Trepal et al., 2014). Without clear guidelines on how mentoring might support doctoral student mothers, current mentoring programs and training practices may be inadequate. In this study, we sought to investigate the mentoring experiences of students who were navigating the dual roles of mother and student in CES programs. Although past studies have explored mentoring programs of doctoral students (Clark et al., 2000; Holley & Caldwell, 2012; Ku et al., 2008) and the experiences of student mothers in doctoral programs (Holm et al., 2015; Trepal et al. 2014), we sought to determine how mentoring benefits doctoral student mothers.
Qualitative research is a suitable choice for investigating questions pertinent to counselor education, as it lends itself to rich data collection through interactions between the researcher and participants (Hays & Singh, 2012). A subset of qualitative research, phenomenological research is aimed at increasing understanding of the complexity of people’s lives by examining the individual and collective experience of a particular phenomenon (Creswell, 2013). We chose a phenomenological approach to understand how student mothers experienced mentoring while in a CES program. This seemed to be the best lens through which to explore our research question: What is the lived experience of doctoral student mothers formally or informally mentored by faculty and/or peers? With a greater understanding of this phenomenon, counselor educators may apply this knowledge in recognizing and meeting the needs of student mothers to reduce attrition.
Our research team consisted of a doctoral student mother (first author and now a faculty member) and three faculty members in a CACREP-accredited CES program at a small, private university. During their doctoral studies, two of the three women were mothers of young children and the male faculty member became a first-time father. Currently, the faculty researchers are advancing through their tenure track while parenting elementary-age children.
Before the study, we met as a team to discuss our experiences of mentorship as students and junior faculty as well as how we experienced the climate of our institution toward families. The first author shared that her research interest grew out of her own experience as well as the struggles of doctoral student mothers in her cohort, necessitating support from peers and faculty members. Eager to learn how doctoral student mothers experienced faculty and peer mentoring across institutions, we watched this study begin to take shape. Acknowledging our biases and bracketing our assumptions, we set them aside to allow a fresh perspective of the participants’ experiences to emerge. LeVasseur (2003) described this process of bracketing as suspending understanding of the topic to shift toward a position of curiosity.
Procedure and Participants
After receiving approval from the university’s Human Subject Review Committee, we recruited participants using a professional counseling electronic mailing (CESNET-L) and by emailing CES department heads at four universities in the Eastern United States. The email provided criteria for the study with a link to the demographic questionnaire and informed consent form. Criteria included: (a) completed at least one year of doctoral studies in a CACREP-accredited CES program or had graduated within 2 years; (b) formally or informally mentored by faculty, peers, or both; and (c) mother of at least one child below the age of 18 residing with them during their counselor education doctoral training. Not wanting to limit participants because of location, we chose to interview participants using a telehealth video platform. This resulted in a wide geographical sample as shown in Table 1. University types included three Research 1, one historically Black college and university (HBCU), one hybrid, and seven liberal arts institutions. Twelve participants were selected to be interviewed based on meeting criteria and in keeping with sample size guidelines for phenomenological studies (Creswell, 2013). Participants ranged in age from 29–37 (M = 34, SD = 2.4). Participants identified racially as European American (n = 9) and African American (n = 3). Ten became pregnant during their doctoral studies: six were first-time mothers, and two miscarried twice. Children’s ages ranged from 10 months to 12 years, with most under the age of 3. In addition to being students, all participants were employed during their studies as school counselors, in private practice, or in agency clinical work. Six of the seven interviewees were employed as an adjunct professor, school counselor, researcher/consultant, program director of a counseling department, private practice counselor, and university counseling center director; the seventh was a new doctoral graduate.
Participant Demographic Information
|Status in CES
|Pregnant While in Program
||Ages of Participants’ Children
||Type of Mentor
||3 years or under
||4–6 years old
< 6 months
||7–12 years old
||13 years old +
Each participant completed a demographic questionnaire and signed an informed consent form for voluntary participation. The questionnaire inquired about age; sex; race/ethnicity; relationship status; length of time in the CES program; year graduated; if they were pregnant or adopted children and the number of children/their ages while in the program; and if they were mentored by faculty, peer, or both.
The first author conducted the 12 interviews through V-SEE, a Stanford-created, telehealth videoconferencing application that supports online collaboration. It allowed the participants and research interviewer to interact synchronously via audio and video. Interview length ranged from 60–75 minutes as participants described their mentoring experiences. The interview settings were descriptively “in the field,” as they were interviewed in their offices, cars, and homes. Three had their babies/toddlers with them during the home interviews. Participants described their university type, cohort structure, and employment status. The first author asked each participant open-ended questions using a semi-structured interview format developed from our review of the literature on mentoring, motherhood, and issues concerning doctoral student mothers. The questions included: (a) “What factors, if any, influenced your decision to be mentored?” (b) “Can you describe your mentoring experience in detail?” (c) “Can you speak to your work–study–life balance while being mentored?” (d) “Can you speak of your academic progress and/or professional development while being mentored?” (e) “Describe the characteristics or traits of a mentor that are important for doctoral student mothers,” and (f) “What, if anything, could a counselor education department do to promote successful mentoring experiences for doctoral student mothers?” With qualitative inquiry, the goal is to include enough participants to adequately understand the phenomenon in question (Hays & Singh, 2012). Wanting to capture a fresh perspective from these doctoral students who were mentored, many while becoming mothers for the first time, all 12 interviews were retained, yielding in-depth descriptions of their experiences. Pseudonyms were assigned to participants prior to data analysis to protect their identities.
Phenomenological data analysis is concerned with examining participants’ experiences to understand the depth and meaning of those lived experiences (Hays & Singh, 2012; Moustakas, 1994). Delving into large amounts of transcription data, the goal is to develop a composite description or essence of the experience that represents the group as a whole (Moustakas, 1994). The first author began the inductive method of analysis by engaging in horizontalization, the process of identifying non-repetitive, non-overlapping statements from the first three interview transcripts (Hays & Singh, 2012; Moustakas, 1994). Next, the first author clustered these statements in units of meaning or themes and then wrote textual descriptions of “what” the participants experienced, including verbatim examples from the transcripts (Creswell, 2013; Moustakas, 1994). The first and second investigators met weekly to discuss and rework these themes. From there, they wrote a structural description, “how” the experience happened in the context of the setting or circumstances and who was involved (Creswell, 2013; Moustakas, 1994). The first author used these themes to analyze the rest of the transcripts with care given to reanalyzing previous interviews as new themes or subthemes emerged. The team met to finalize the central themes and subthemes that emerged collectively from the participants’ reflections, contextualizing them into a holistic understanding of the essence of the mentoring experience (Hays & Singh, 2012).
Validation strategies included recognizing and controlling for research bias through bracketing, capturing participants’ viewpoints through substantial engagement, and triangulation through cross-checking codes and themes and by using thick participant descriptions (Denzin & Lincoln, 2011; Lincoln & Guba, 1985). Using basic member checking, participants reviewed their transcripts for accuracy, with two making clarifying comments (Creswell, 2013; Hays & Singh, 2012). The first and second authors met weekly to process reflection notes to bracket any biases and discuss themes to allow triangulation of data (Creswell, 2013; Hays & Singh, 2012). The two other members of the team reviewed the themes/subthemes matched with descriptive statements for cross-checking purposes (Hays & Singh, 2012; Lincoln & Guba, 1985). To address confirmability and transferability, they kept an audit trail beginning with interview notes, transcripts, reflective journals, and coding pages with descriptive statements. Finally, the authors provided thick descriptions, allowing the reader to enter into the study to a greater degree to reach their own conclusions and stir further discourse around these critical issues in counselor education (Denzin & Lincoln, 2011).
Three overarching themes centered on identity: the qualities and shifting identities of doctoral student mothers, the qualities and roles of faculty/professional and peer mentors, and the barriers and hardships that led to losses and unmet goals despite mentorship experiences. Participants shared how mentoring evolved around their identities as mothers, students, and professionals; what they experienced as support or discrimination by faculty and peers; how their mentors served as a protective factor despite hardships and barriers; and what was needed in terms of advocacy to successfully develop counselor educator identities.
Theme I: Identities and Qualities of Doctoral Student Mothers
Perseverance and resilience characterized the lived experiences of these doctoral student mothers facing unexpected challenges that threatened to slow progress or impede career goals. Sara, who found out she was pregnant shortly after being accepted into her doctoral program, shared, “I ended up having a really horrible labor and a C-section. My baby spent the first week in ICU. We were only home a short time after having major surgery, but I still went back to school 3 weeks later.” Natalie also shared her version of perseverance: “I took my comps when I was 38 weeks pregnant [laughter]. I had to keep standing up and going to the bathroom. ‘Then I said, I can have this baby now!’”
Making the shift from student to mother or mother to professional requires integrating multiple identities and corresponding roles. “I always had it drilled into my head by my mother that I would be called ‘doctor’ before I was called ‘mom.’ So many of us are both education-oriented and family-oriented, being in counseling,” remarked Allison. Similarly, Lisa voiced how she embraced her changing identity: “You grow in confidence as a person and through motherhood. Learning what worked and what didn’t work. Just having a better sense of myself, my strengths, knowing my worth, knowing my value, and just feeling secure in it.”
With the multiple identities came the challenge of meeting academic rigor and motherhood responsibilities, often with conflicting timelines. Although all the participants described themselves as serious students, they made it clear that their children were their number one priority. They willingly sacrificed time and personal needs in hopes of careers that offered greater flexibility and financial stability. “Yes, you’re exhausted because you are running a marathon every single day. At the end of the day, you don’t have that little space for yourself,” said Lisa. Mothers often felt the pull between having to choose work or studies and time with their families. Bethany, a school counselor, explained, “I struggle with mommy guilt even with my job, as my child is one of the first ones in the building and last ones to leave every day.” Bethany also recounted, “One of the biggest mom guilts is a picture of my child around the age of 5. I am sitting in a chair surrounded by books and papers as he fell asleep on the couch waiting for me to do something with him. That was really tough.” Amy described her typical schedule:
I get up at 6:00, play with the kids, get them off, and get to work . . . until 10:00 pm, kids come in my bed and snuggle. Then I finish grades and go to bed at 3:00 am. 100% of the weekends are dedicated to the children. Want them to say . . . ‘Mom was present.’ That’s hard when the career path and academics are so consuming.
Lisa felt inadequate in both roles at times: “I’m working so hard. . . . and I am not a good enough mom and I’m not a good enough student. . . . not doing a great job at anything.”
Several participants reported that their mentors helped them establish healthy boundaries and taught them how to prioritize commitments. Tonya shared, “Today is going to be about work . . . or today is going to be about school. I appreciated having faculty members who had young families, knowing that someone understood that.” When the demands of work became unhealthy, Bethany revealed it was her mentor who said, “You’ve got to reshuffle. You are drowning, and you are miserable. You have to let some of this school stuff go.” On prioritizing, Natalie shared, “When I went into this program, I said that I am not going to miss anything in my personal life, even if it takes 4 or 5 years.”
Doctoral student mothers commonly identified as non-traditional students. Not only was this gender-influenced, it was also the result of added caregiving responsibilities that prevented them from engaging in opportunities afforded to traditional students. They often felt isolated from their peers or labeled as less committed, which resulted in differential treatment and exclusions. Lisa explained:
I always felt like some kind of outlier . . . like all the other cohorts are like these tight little units. I’m always slipping in and then dropping back out. Would see them on Facebook all hanging out and going out for drinks . . . or they would be publishing or going to conferences. I was working and taking care of children.
On being non-traditional, Morgan, a mother of two, working 25–27 hours per week, shared, “No one in my cohort had children and none had outside jobs.” Several participants noted how their male counterparts were able to go full-time without having to deal with family-related interruptions, be questioned for having babies, experience guilt when traveling, or juggle as many commitments. Kayla, reflecting on experiencing negative remarks about her clingy child when she had to travel for work, noted, “They had wives that stayed at home, so their experience has been completely different.” On comparing her needs to those of traditional students, Lisa shared, “Mentoring for students who don’t have kids, it’s . . . talking about publishing together or presenting together. For me, it really is how are you helping me navigate this program.”
Theme II: Identities and Qualities of Effective Mentors
For all participants, mentoring was more than academic advising. Often, it was the mentor’s combined qualities of temperament, leadership, scholarship, and friendship that helped these doctoral student mothers navigate their programs effectively. Participants described the criteria for selecting their mentors: specific personality traits, women who were also mothers, who shared research interests, and those who modeled career–life balance. The three African American women also considered race an essential factor in mentor selection. Tonya, the sole woman of color in her cohort, connected with other African American faculty outside her department and graduates who were mothers, while Dana experienced mentoring by most of the faculty at her HBCU. Allison based her mentorship selection on personality: “I needed someone who doesn’t have my exact personality but who can keep my ideas focused and keep me on track—tough, but supportive.”
Some chose female mentors because they believed they would provide greater support and speak to the female experience in academia. Lisa’s mentor selection was through gender matching: “I chose the only woman in my program that has children . . . so I feel like she gets me, and she gets the experience of motherhood and has a great perspective on things.” Amy shared that her mentor “could speak to my strengths and could commiserate the experience of being a woman in academia.”
Participants described effective mentors as encouraging, supportive, and flexible, displaying qualities of warmth, empathy, and trustworthiness. Most depicted their mentors as master cheerleaders and challengers. Morgan explained that two mentors filled different roles: “I have the mentor’s office that I go cry into . . . and the office that I go in and come out sharper for. I think you need both of them.” Sharon chose four mentors: “One was especially about writing and research . . . one that was just about my self-care and well-being, and one primarily about the academics. . . . [and] one that kind of combined it all, but who I could talk to about the mommy guilt.”
Mentors provided a balance between the demand for excellence and practicality and compassion. Creative flexibility and realistic expectations without judgment rounded out the mentors’ qualities. Mentors were available beyond the usual office hours and willing to meet at convenient locations such as a coffee shop or home. Morgan commented on the open-door policy of her mentor: “Availability is important. You can walk in and talk . . . whether it is just casual conversation or coming in with a need.” Participants described how their mentors went above and beyond to provide creative accommodations. Lisa shared the flexibility of her mentor: “We co-taught and she would work around whatever my schedule was. We would have meetings after the kids went to bed. She really understood my situation and was just so affirming.”
Mentoring had a personal side that provided not only a safe interchange of ideas but allowed for vulnerability and transparency. As doctoral student mothers verbalized their hardships, their trusted mentors were not only an emotional outlet but a therapeutic balm providing empathy and care. Their mentors often shared similar lived experiences that created a deeper connection, emotional bonding, and lasting friendship. Sharon found comfort when she faced a personal challenge: “My youngest child was diagnosed with autism very early. When I went to my mentor, she shared that her child was diagnosed with autism as well. We were able to connect and really process our lives as working moms.” During hardships and personal challenges, mentors provided comfort and encouragement. Tonya shared how her mentor was there for her after her miscarriage: “I told [my mentor] that I had this little person inside of me and now I don’t. She started crying and asked me, ‘What do you need right now?’” Tonya’s mentor encouraged her to put off writing her comps for a semester to process the loss.
Effective mentors provided professional modeling and career guidance, being personally supportive while navigating the logistics of becoming a counselor educator. Mentors endorsed them for leadership positions, taught them how to negotiate salaries, and helped create a pathway for career satisfaction. On developing their professional identity, graduates were indebted to the mentors. Bethany explained how mentorship groomed her for research: “When I was accepted to the program, [my mentor] took me under her wing and said, ‘Let’s find a research project to do together.’ So we wrote a grant for it and she mentored me through that whole process.” Natalie explained how her mentor helped develop her professional identity: “She pushed me to see myself better. . . . something that women have a hard time doing is advocating for themselves in the workplace. She not only modeled that, but she taught me how to do it.”
Participants valued the family orientation of their mentors and voiced the need for their mentors to be family advocates. Without these advocates, many felt unequipped to compete with negative voices and dismissive attitudes. Allison shared her experience of feeling supported in her decision to get pregnant:
My advisor/mentor and I were having one of those heart-to-heart conversations. I actually started crying and said, “All my husband and I talk about is babies . . . every weekend. I’m ready; but education-wise, it just doesn’t seem like a possibility.” My advisor looked me straight in the eye and said, “If you want a baby, have a baby.” I shouldn’t have needed permission, but I wanted to know that I was going to be supported.
Mentors helped doctoral student mothers create timelines that respected their family needs as well as their academic and professional goals. Morgan’s mentor said, “We’ll navigate your schedule in an appropriate way that works for the program and for your family.” She then built her plan based upon her schedule and personal journey.
Effective mentoring paralleled hallmarks of counselor education in promoting wellness, advocacy, and empowerment. Seven of the 12 described how their mentors practiced good self-care and modeled positive well-being. Allison discussed how her mentor helped to put work–life balance in perspective: “She was a role model of balance. She would say, ‘You’re working too hard. You need to spend some time with your family.’ I have been able to come out of the program . . . [with] great work–life balance.” Mentors’ practice of self-care made it easier to emulate wellness practices and achieve greater work–life balance. Allison summed it up: “My mentor has this beautiful, wonderfully doting family. . . . Successful children, a supportive husband, and a career—that’s the type of woman I want to be.”
Participants described how mentoring served as a protective factor in reducing attrition. Their rich mentoring experiences helped them succeed in the program and manage the challenges of conflicting roles. Their mentors’ encouragement and support became their lifeline through transitions such as marriage, pregnancy, divorce, and illness. Mentors were especially protective of participants facing cultural or institutional barriers, advocating during their pregnancies and beyond. Allison described how she felt protected from other faculty by her mentor throughout her pregnancy: “I was tired a lot during my pregnancy. If other faculty members got upset that I wasn’t able to fulfill a requirement, she went to bat for me . . . supporting me by saying, ‘Well, in all fairness, she is pregnant.’”
Qualities of Peer Mentors
Three-fourths of the participants were peer mentored, having sought out peers who were also mothers. Although only two of the participants were involved in a peer mentoring program, all 12 conveyed the value of having a more senior member of their program available for questions, advice, encouragement, and engagement in academic activities. Many shared how mentors offered supportive advice, as they were familiar with the journey ahead. Nicole said, “Peer mentoring is beneficial because you get to see someone who has recently been there, and having others from older cohorts can provide help and insight.” Participants gravitated toward other mothers who understood their plight and built mentorships based on the common ground of motherhood intersecting with student life. Peer mentors shared their journeys, insider information on coursework, and realistic timelines; they became fellow presenters and publishers, and provided encouragement along the way. Bethany shared that she often wrote with a peer mentor who understood when she said, “Let’s have a realistic mom timeline.” Natalie shared the reciprocal nature of peer mentoring: “She and I relied a lot on each other just for support and mentorship. She had her baby 6 months before I did and I am learning a lot about the work–life balance and stuff from her.”
Peer mentorship was relational as well as academic. Several participants shared how peer mentoring helped reduce feelings of isolation, as their availability for meet-ups and socializing differed greatly from their peers who did not have children. Tonya explained how she was able to receive encouragement over mommy guilt from a peer mentor who was also a mother. She “talked to her a lot about what worked for her, how she really tried to put her son first . . . which was helpful for me to hear, because I just felt terrible about it all the time.” Navigating the program without a faculty mentor, Kayla found much of her support through her peer mentor: “We became close and she would let me know about the things to be looking for, to be preparing for upcoming classes. She really had my best interest in mind.” On the close friendships forged through mentorship, Dana stated, “She has become my sister. . . . We talk about frustrations, helping me lay boundaries and be okay leaving my child.”
Participants provided specific ideas as to how to implement peer mentorship programs. Ideas included identifying other student mothers for networking opportunities and information, such as childcare services, understanding school policies, and general support. They also recommended working through organizations such as Chi Sigma Iota to create networks, organizing graduate student meet-ups that are family-friendly, and having older cohorts reach out to newer cohorts throughout the year.
Theme III: Identifying Barriers Facing Doctoral Student Mothers
Stigma and discrimination, lack of accommodations, and need for advocacy emerged from the participant interviews. These barriers produced the hardships these mothers encountered, generating losses and unmet career aspirations. Ten out of 12 expressed awareness of faculty and students’ bias toward non-traditional students, especially women who had families. A majority of the participants felt that as doctoral student mothers, they did not have a strong voice in the institutions that they represented. Often, attitudes of faculty toward doctoral student mothers were dismissive and discriminating when they did not fit into the traditional mold of academia. Others determined that faculty and department heads were simply unaware of the hardships and needs of student mothers and therefore perceived them as less motivated or incapable of meeting the rigorous demands of academia. Perhaps some experienced it most deeply through the lack of research and training opportunities, such as graduate assistantships (GA). Amy discussed her frustration and discouragement at being overlooked for a GA position: “I got the strong inclination that it was because I [got] married and that I couldn’t dedicate myself as a typical GA. . . . I would have liked to have been given a chance to prove myself.”
Others also felt that their limited visibility resulted in biased and discriminatory attitudes from faculty and peers. Lisa explained feeling written off as “not the person looked [at] to do a presentation with someone or to do a publication.” While her peers were writing with faculty, she regretted that she couldn’t “be physically present . . . especially when [she] was working and trying to juggle all of these roles.”
Over half of the participants experienced negative attitudes toward their decisions to marry or start their families while in their doctoral programs. Lisa shared that “a faculty member told me point blank that I shouldn’t have a second child in the program.” Amy shared the messages she received on becoming pregnant in her last year of coursework: “Comments from students and faculty were like ‘Why can’t you just wait until after you are done as you are so close?’ or ‘What are your plans when you have a kid?’” Bethany explained how the faculty’s lack of understanding of her minimum progress on her dissertation during her season as a mom, new wife, and full-time school counselor was demoralizing: “For my [program evaluation] this year, I received a grade of no progress in all areas . . . so I have two articles published and won a regional school counselor of the year award. I walked away feeling like I don’t measure up.”
Many participants spoke of the feeling of invisibility as doctoral student mothers by the lack of accommodations such as lactation facilities, childcare options, and clear or even existent leave of absence policies. Of the participants interviewed, only two spoke of having access to childcare on campus. Most had to rely on partners, parents, babysitters, or other students to meet these needs, especially those needing evening hours or experiencing long commutes. During emergencies, when childcare failed or a child was sick, these mothers were at the mercy of professors, department chairs, and supervisors to decide if they could get coverage for their duties or bring their babies to meetings, classes, or groups. Few felt childcare issues or illnesses were justification for missing classes or meetings. Similarly, lactation facilities were haphazard, as the majority of buildings had no dedicated nursing rooms. These new mothers had to use student lounges, borrow windowless offices, pump in their cars, or get up early to pump to avoid the hassle on campus. Sharon revealed that “the only place to pump was the bathroom or car. I don’t feed my child in the bathroom so I’m not pumping in the bathroom.”
Finally, participants described frustration over the lack of clear policies when attempting to stop the doctorate clock for maternity leave and in taking time off from assistantship positions that carried weighty financial penalties. Some maneuvered through with placeholder internships, others accumulated hours so that they could take off after their babies were born, and still others shifted down to part-time. In most cases, their mentors helped them find the path of least hardship and greatest flexibility. Lisa reflected on a lack of clear policies: “There need to be better structures to support women and support children. It shouldn’t all have to fall on me, because I’m always going to come up short.” Despite these barriers, five participants were satisfied with the support provided and viewed their department as accommodating non-traditional students effectively even with ambiguous policies.
Regardless of the hardships encountered, what participants regretted the most was their unmet career aspirations. These doctoral student mothers worked diligently to complete their programs but often had significant delays. The range of doctoral completion/expected completion was 3–7 years. Some regrets included not being able to complete hours for licensure, having fewer research opportunities, presenting less often at conferences, and missing out on other duties that would have enhanced their curriculum vitae. Allison lamented her losses: “I wasn’t able to commit the time to seeing clients, as I didn’t want to be at the clinic until 9:00 pm when my son goes to bed.” Lisa added humor to her dilemma of unfulfilled aspirations: “I want to be a full-time faculty member, tenure track at the end of this. That is going to be really challenging because my CV is very short. I am going to attach pictures of my children.”
Call for Advocacy and Awareness
Although discrimination and other barriers in higher education institutions were fairly commonplace, participants articulated several solutions: (a) expand mentorship opportunities, (b) teach and model work–life balance, (c) improve accommodations for students with families, (d) provide professional opportunities around flexible scheduling, (e) increase awareness and support from faculty, and (f) promote advocacy at departmental and university levels. Five participants had already positioned themselves in the role of mentors and advocates for those coming behind them. Three were involved with research that highlighted these issues. “Mentorship should be a requirement and not an option because we know we work well if we have mentors,” remarked Sharon. Dana suggested that graduate programs should survey students to determine the climate of the program and if students are receiving mentorship, and identify mentors who could best address their needs. Bethany believed that universities must expand mentorship, even if it means extending beyond department lines: “Counselor ed departments need to say, ‘Hey, we can’t meet all of your needs as a mother, or a single mother, but I know someone who can, and I want to be intentional and connect you with this person.’” Bethany also suggested that “peer support groups would be really cool. I was the ‘lone wolf’ for a little bit. Could create campus-wide support groups for graduate students . . . and provide childcare and free pizza for the kids.” The important piece was not having to navigate this alone, as Sara remarked: “Facilitating connection between doctoral student mothers, rather than us having to find our own connections, would be helpful. Making sure there’s a space for moms.”
The main component named was to increase the visibility of the needs of student mothers and provide an understanding of their experiences by shifting the mindset of lowered expectations by faculty and peers to knowing that they can and will be successful with support. Advocacy requires understanding the experiences of women, especially mothers, and identifying the barriers they still face in academia and the workplace. Sara shared the need for greater equity for doctoral student mothers, saying that it “isn’t fair that women who have decided to be moms have to put their own dreams secondary. Women need to know that they are welcome and there is a place for them if they do decide to get pregnant.”
Participants suggested that counselor education programs should teach how to create a framework of work–life balance. Flexible timelines were part of the template for success. Allison suggested that timelines could be a helpful option for those considering doing both doctoral work and motherhood, because her mentor said, “Don’t do it until after second year . . . [it’s a] lot easier to stop and start the dissertation process.”
Providing for physical needs, such as having a lactation room, was also critical to sending a welcoming message. Participants described the need for maternity and sick leave policies that were family-friendly. Participants agreed that they needed faculty and departments to acknowledge their capability to complete their doctorates, accept their value to the profession, and support their life choices. Allison voiced a clear directive for faculty and peer mentors:
The biggest characteristic needed for a mentor is supporting and that it just takes one person . . . one relationship at the school who was going to be accepting of me regardless and who was going to help me with my goals . . . not just my goals to be a PhD but [my] goal to be a mother and a good wife.
Participants’ voices highlighted how, with the support of their mentors, they were able to navigate the often murky waters of a PhD program. Perhaps because 10 of the 12 mothers were pregnant while in their program, they neither cared nor were able to hide their motherhood identity. This is only the second study at the time of this review that specifically included women who were pregnant while in CES programs. Similar to the findings of Holm and colleagues (2015), these participants viewed motherhood as a positive attribute that blended well with CES principles in enhancing their work and vice versa.
Participants experienced mentoring as relational and protective. Building on the findings of several studies that suggested mentoring might add a protective factor for success and satisfaction (Holm et al., 2015; Lynch, 2008; Neale-McFall & Ward, 2015; Trepal et al., 2014), this study found that mentors focused on providing logistical support to bolster academic progress while fostering work–life balance to promote the overall well-being of the student. These mentors provided emotional support for the participants’ decision to become pregnant and provided regular check-ins throughout the pregnancy, new motherhood, and in many cases, beyond graduation into a professorship.
Also important to this study was the reciprocal relationship. Beyond responding with care and compassion, mentors shared their own motherhood experiences that mirrored their mentees. Supervisors who expressed vulnerability increased the feeling of friendship and deepening of the relationship. This supported other research that described mentoring relationships that include an emotional connection that was both empathic and empowering (Gammel & Rutstein-Riley, 2016; Holm et al., 2015; Trepal et al., 2014). In a similar finding to that emerging from Kelch-Oliver and colleagues’ (2013) study of mentorship, the three African American participants experienced “mothering” by female African American faculty mentors and the “sisterhood” of peer mentoring that went beyond academic walls. For these women, mentoring helped navigate cultural barriers. Not only was it important that they have female faculty, but also choosing women who lived under “double minority” as Patton (2009, p. 71) described gave them both perspective and support around the complexity of race, gender, and motherhood in academic settings and society as a whole.
Doctoral student mothers connecting with other student mothers reported experiencing greater encouragement and satisfaction in those academic peer relationships compared with their relationships with peers without children. Similar to previous findings (Lynch, 2008; Trepal et al., 2014), peer mentoring by other student mothers reduced feelings of isolation, as often these women were the sole mothers in their cohort. They relied on other mothers in earlier cohorts or recent graduates to guide them on how to balance academics and family life.
Participants who had wellness and work–life balance modeled felt better equipped to pursue an academic career path, while those who had poor work–life balance modeled felt less prepared to be successful in academic institutions. Participants who experienced greater discrimination from their institution lacking in family-friendly policies shared their intentions to put their family’s needs first by accepting non-academic jobs, moving closer to relatives, or waiting until their children were older to enter a tenure-track position. This coincides with decades of research (Alexander-Albritton & Hill, 2015; Wolfinger et al., 2008) on graduate women with academic careers that are perceived as non-supportive of family–work balance.
Results also gave voice to the need for change that promotes advocacy concerning parenthood and family-friendly accommodations to aid in decreasing discrimination, both structurally and psychologically. These women had already become advocates and peer mentors. Congruent to earlier research findings, participants identified the need for institutional support in the form of establishing peer mentorship networks that connect other mothers across cohorts and departments, clarifying maternity leave policies, adopting non-penalizing pause-the-clock policies for dissertation work, offering accommodations such as lactation rooms and childcare, and providing flexibility around timelines (Holley & Caldwell, 2012; Holm et al., 2015; Lester, 2013; Lynch, 2008; Stimpson & Filer, 2011). Finally, participants challenged counselor educators to lead the way in addressing inequalities and dismissive attitudes of motherhood in academia by creating a level of openness to family life and choosing to support their students’ goals as counselor educators and mothers.
Limitations and Future Directions
This study has limitations because of transferability issues, the possibility of research bias, and delimiting criteria. Although major geographic regions and university types were represented, participants were racially, culturally, and economically similar, as all were married and in dual-income families. As this study recruited only mothers in CES programs, implications from this study for doctoral student fathers who are primary caregivers or doctoral student mothers in other disciplines may not be transferable. Additionally, several mothers in this study had children with medical or mental health issues, but this study did not specifically set out to focus on families with special needs.
Concerning the research design, as research instruments, we may have inadvertently interjected personal biases into the interview process and coding. The goal was to minimize this through bracketing, journaling, member checking, and reviewing themes with research members. Although semi-structured interview questions guided the research and allowed for organic responses, perhaps another approach might have yielded additional themes. All the participants held jobs in addition to their studies and motherhood duties. Several discussed the effects of work on life balance and needing to reduce hours to part-time, but no distinct theme emerged. Perhaps a specific question on how mentoring may mediate the strains of employment might reveal additional content. Finally, the experiences recorded represent women who remained in their programs. With attrition close to 50% (Council of Graduate Schools, 2010), this research did not address those who dropped out of the program, so other needs or barriers may be missed.
Suggestions for future research include either expanding the concept of caregiving or narrowing the focus to specific sub-groups. Specific to CES, research might investigate mentoring from a faculty point of view to determine why and how faculty choose to mentor, as well as any training for the role. A focus group or interviewing both the mentor and other faculty who interacted with these student mothers might also add to the thickness of the context. Revealed reciprocal benefits that mentors and mentees incur in their relationship could be applied to future training programs for counselor educators. A study specific to peer mentorship might yield unique findings and inform strategies for launching or enhancing successful programs. Quantitative studies might evaluate the effectiveness of existing mentoring programs and expand them for non-traditional students.
Findings from this phenomenological study are cautiously optimistic, as they appear to strengthen the body of knowledge around the importance of relational mentoring and suggest it may be an important protective factor for doctoral student mothers. Research suggests that mentoring is an effective means of support for women (Bruce, 1995; Holm et al., 2015; Kelch-Oliver et al., 2013), but in this study, it appeared to be the most salient component for successful completion of their doctoral programs. Combining the effects of dual roles, medical and mental health hardships, isolation, lack of family-friendly accommodations and policies, and struggles with work–life balance made the mentoring experience essential.
Adding to the body of knowledge around mentoring, this research denotes specific qualities of effective mentors and provides rich descriptions of the relationships and roles valued by these student mothers. This may be helpful in CES training, in selecting future mentors, and in setting up mentorship programs. Equipped with clear directives, CES departments can develop mentorship programs, pairing senior professor mentors with junior professors to teach mentoring skills, rewarding faculty for outstanding mentorship, establishing peer mentoring programs, and developing alumni mentorship opportunities. Within programs and across campus, faculty and staff can assist in connecting student and faculty mothers, promote family support groups, and organize family-inclusive activites. Meanwhile, counselor educators can provide flexibility around scheduling comprehensive exams, dissertation timelines, and research opportunities. Counselor educators can lead in bringing this issue to the discussion table around program development and advocacy initiatives. Medina and Magnuson’s (2009) statement that “Mothers are the people through whom others’ lives are changed” (p. 90) fits well with the ideals of counselor educators; therefore, retaining these mothers in higher education is an important endeavor.
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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Vanessa Kent, PhD, NCC, LCMHC-S, LMFT, is an assistant professor at Regent University. Helen Runyan, PhD, NCC, LPC, is an associate professor at Regent University. David Savinsky, PhD, ACS, LPC, LMFT, CSAC, is an associate professor at Regent University. Jasmine Knight, PhD, NCC, is an assistant professor at Regent University. Correspondence may be addressed to Vanessa Kent, 1000 University Drive, Virginia Beach, VA 23464, firstname.lastname@example.org.
S Anandavalli, John J. S. Harrichand, Stacey Diane Arañez Litam
Amidst the global health crisis of COVID-19, international students’ safety and well-being is threatened by community- and policy-level animus. In addition to adjusting to a foreign culture, a series of draconian policies and communal hate crimes during the pandemic have placed international students in an especially vulnerable position. In this context, professional counselors must be well prepared to support this community. The authors describe the current sociopolitical events that have adversely impacted international students in the United States. Next, challenges to international students’ mental health are identified to aid counselors’ understanding of this community’s needs. Finally, recommendations grounded in critical feminist and bioecological approaches are offered to facilitate counselors’ clinical and advocacy work with international students.
Keywords: COVID-19, international students, critical feminist, bioecological, advocacy
COVID-19–related fears have resulted in social and political responses characterized by racial discrimination and xenophobia toward marginalized groups (Devakumar et al., 2020; Litam, 2020; Litam & Hipolito-Delgado, in press), including international students (Anandavalli, 2020; Zhai & Du, 2020). Rates of misleading media portrayals and xenophobic rhetoric substantially increased after President Trump referred to COVID-19 as the “Chinese virus” on March 16, 2020, and have steadily risen across social media platforms (Lyu et al., 2020). Exposure to COVID-19–related racial discrimination has deleterious effects on the mental health and life satisfaction of racial minorities (Litam, 2020; Litam & Oh, in press; Wen et al., 2020), including international students residing in the United States (Zhai & Du, 2020). The extant body of literature has clearly established lower levels of help seeking, barriers to counseling, and increased rates of mental health distress among international students compared to their domestic counterparts (Auerbach et al., 2018; Clough et al., 2018; Sawir et al., 2008; Zhai & Du, 2020). These existing challenges and psychosocial stressors may uniquely combine with current sociopolitical messages and policies to further exacerbate the unique developmental and cultural stressors encountered by international students. Thus, counselors working in various roles (e.g., college counselors, private practitioners) are called to develop a deeper understanding of the ways in which international students are negatively affected by xenophobic policies following COVID-19 and to employ culturally sensitive strategies grounded in systems approaches.
Although all counselors working with international students must consider the impact of larger systemic issues on international students’ mental health, college counselors might be in a unique position to support this population because of their close proximity. Counselors must consider how the combined effects of sociopolitical influences, systemic inequity, intersectionality, and COVID-19–related experiences of xenophobia uniquely contribute to the mental health disparities of international students in a post-pandemic reality. It is vital that counselors consider the impact of social and political structures, as Anandavalli (2020) found that contextual and systemic influences (e.g., elections, travel bans, anti-immigrant sentiment) have a profound impact on international students’ mental health. Unfortunately, despite repeated calls to action, counselors may be unprepared to support international students in the United States (e.g., Kim et al., 2019). Even years after Yoon and Portman’s (2004) critique, accredited counseling programs continue to offer little to no training to students to work effectively with international students. Perhaps as a result of years of limited training and research on international students’ mental health experiences, counselors continue to have inadequate cultural competence when working with international students. In a recent study, Liu et al. (2020) noted that although Korean and Chinese international students in their study had a cautiously optimistic attitude toward their college counselors, a third of them felt hurt and disappointed by their college counselors’ cultural incompetence and reported incidents of counselors’ cultural ignorance and stereotyping. With limited attention to social justice and equity issues, counselors can further traumatize and alienate some international students (Jones et al., 2017).
Within the counseling literature, even the few studies that explored the mental health of international students from a relational and systemic perspective (e.g., Lértora & Croffie, 2020; Page et al., 2019) have failed to adopt a critical lens and examine the impact and accountability of larger social institutions on the community’s well-being. At present, a review on PsycINFO, Google Scholar, and SocINDEX using the search terms international student mental health, international students counseling bioecological model, and international students multicultural critical race theory yielded no counseling literature that addressed strategies to support the mental health of international students in the United States from a critical perspective. Thus, the following article contributes to the extant body of literature on the topic by (a) describing the ways in which current sociopolitical events and policies send denigrating messages that devalue international students, (b) outlining the mental health challenges of international students, and (c) offering specific suggestions for counselors working with this vulnerable population through a critical feminist and bioecological lens.
Sociopolitical Policies Affecting International Students
According to the Institute of International Education (IIE; 2019), as the most popular study abroad destination, the United States hosts more than 1 million international (foreign-born) students. However, in the context of the racialized COVID-19 pandemic, Chirikov and Soria (2020) found that as many as 17% of the surveyed international students have experienced xenophobic actions that threaten their safety and presence. Further, they found these rates were higher among students from East Asian and Southeast Asian countries such as Japan, China, and Vietnam (22%–30%), given increasing Sinophobia (anti-Chinese sentiment) in the country. In addition to pursuing higher education, each year thousands of international students seek post-education professional experiences to receive practical training through an H-1B visa. An H-1B visa authorizes international students and professionals to work in the United States because of their experience in specialty occupations of distinguished merit and ability (U.S. Department of Labor, n.d.). On June 22, 2020, H-1B visa holders were notified that effective June 24, 2020, the U.S. embassy would not be issuing new H-1B visa stamps; additionally, the ruling dictated that without a valid H-1B visa stamp, individuals could not enter the United States until December 31, 2020 (The White House, 2020). This xenophobic proclamation left thousands of international professionals stranded and placed them at risk of losing their employment. The announcement to ban H-1B visa holders devalued international students and professionals in the United States and reminded international students of their fragile futures and conditional status.
The most recent incident in the upsurge of xenophobic sociopolitical messages negatively affecting international students was introduced by the U.S. Immigration and Customs Enforcement (ICE) on July 6, 2020. A few weeks prior to the fall 2020 semester, international students were informed that they would be deported to their home countries if they were enrolled in fully online programs (ICE, 2020). International students became tasked with an impossible decision to either prioritize their health or their education. Unlike domestic students, who could safely attend programs online, the proclamation required international students to attend in-person classes to remain in the country (ICE, 2020). Although the proclamation was later amended to allow international students to attend online courses without deportation (ICE, 2020), the disparaging messages toward international students could not be overlooked. The presence of a discriminatory order that forced international students to choose between their safety and educational training is reflective of larger anti-immigration sentiments that push many students toward an emotional breakdown (Garcini et al., 2020).
Mental Health Challenges for International Students
Although international students contributed about $45 billion to the U.S. economy and to the development of 450,000 new jobs in the United States in 2018–19 (National Association of Foreign Student Advisers [NAFSA], 2020), worldviews that position international students as harbingers of innovation, intellectual diversity, economic success, and a necessity for sustaining higher education institutions are uncommon within American society (Williams & Johnson, 2011). Sadly, experiences of hate crimes are so frequent that many international students perceive them as normal consequences of being an international person in the United States (Lee & Rice, 2007; Pottie-Sherman, 2018). According to George Mwangi et al. (2019), for many international students, universities are far from being spaces of inclusivity and openness. Often, they were described as sites of oppression and “Americanization.” Interviews with international students from Africa indicated that due to their intersecting identities as racial and cultural minorities, participants in the study endured constant messages and actions undermining their culture and knowledge. In fact, persistent incidents of prejudice and discrimination made the participants feel “crazy” (George Mwangi et al., 2019). Chronic exposure to xenophobia, discrimination, and anti-immigrant sentiments has been documented to have profound impacts on international students’ psychological well-being (Houshmand et al., 2014; Ong et al., 2013). As a result of multiple factors, including xenophobia, international students suffer from severe psychological symptoms. One example is a recent study by Dovchin (2020), who found that parochial attitudes toward non-native English speakers and embedded linguistic racism had “serious ‘psychological damages’” (p. 815) on the international students’ mental health. Notably, the impact of “ethnic accent bullying” (p. 815) on her international student participants included development of social anxiety symptoms and suicidal ideation. Given that many of the instances of linguistic racism were found within classrooms, it is imperative that college counselors consider the pervasive influence of systemic inequities on international students’ mental health.
Critical Feminist Perspectives
Critical feminist paradigms acknowledge the powerful role of systemic influences and focus on change at structural levels. These paradigms challenge larger social structures (e.g., national and institutional policies) and promote the pursuit of social justice through clinical practice and inquiry (Moradi & Grzanka, 2017; Mosley et al., 2020). Thus, critical feminist paradigms are grounded in the philosophy that current social landscapes are inequitable and therefore unjust (Bonilla-Silva, 2013). Specifically, the critical feminist theory of intersectionality describes how systems of oppression and the social constructions of race, socioeconomic class, gender, and other identities interact in ways that influence one’s social positioning (Crenshaw, 1989). Given many international students’ intersecting identities as linguistic, racial, and ethnic minorities, counselors must consider how their unique combination of marginalized and privileged identities contribute to their social position and worldview as outlined in the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2015). Consistent with the focus on addressing the pervasive role of sociopolitical systemic influences, the analysis and recommendations offered in this article are grounded in the critical feminist paradigm.
Bioecological Systems Theory
Oppression and change occur across multiple levels of human interactions, and each level may require varied strategies for advocacy on the part of the counselor (Ratts et al., 2015). These interactions range from everyday occurrences in one’s immediate surroundings (e.g., classrooms) to international policies (e.g., travel bans). To address the powerful influence of multiple systems on the mental health of international students, a critical feminist paradigm was applied to Bronfenbrenner’s (1979) bioecological systems theory. The bioecological systems theory outlines how systems and environment interact with an individual in ways that impact their overall well-being. According to the model (Bronfenbrenner, 1994), individuals experience a bidirectional relationship (directly and indirectly) as a result of interacting with environmental systems where the impact of the relationship is dependent on the amount of interaction taking place. The bioecological theory is represented by five concentric circles that expand to represent multiple levels of permeable systems that affect one’s development (Bronfenbrenner, 1994). The systems within Bronfenbrenner’s model include: (a) microsystem, the immediate environment (e.g., family, school, peer group, neighborhood); (b), mesosytem, connections within the immediate environment, such as college campus and roommates; (c) exosystem, external environmental settings that only indirectly affect development, such as religious institutions outside of one’s faith; (d) macrosystem, which refers to one’s larger cultural context; and (e) chronosystem, encompassing patterns and transitions over the course of time and development (Bronfenbrenner, 1994).
Although the bioecological model represents a relatively robust theory, the model is not without its limitations. Christensen (2016) noted that the theory fails to account for the effects of globalization and technological developments that affect various parts of the world differently. These disparities can be addressed by combining the bioecological model with the critical feminist paradigm, which challenges institutions and structures that cut across national boundaries. Both models combine to create a unique framework that may guide concrete recommendations for counselors actively seeking to support and advocate for international students.
Implications for Counseling International Students
As the extant counseling literature on international students suffers from a limited emphasis on a critical feminist and bioecological lens, the current manuscript offers a systemic framework for counseling international students. We invite college counselors to adopt a critical feminist and systems perspective to hold larger systems accountable for their harmful role in international students’ mental health concerns (e.g., a university’s unwillingness to engage in culturally responsive and linguistically inclusive teaching strategies; Archer, 2007). The following counseling recommendations were developed from the authors’ direct experiences through counseling international students, and through a review of relevant literature. Although these recommendations may apply to all counselors irrespective of their settings, some may be specific to a particular role (e.g., college counselor).
The microsystem level includes the bidirectional relationships between the international student and the people with whom they regularly interact (Bronfenbrenner, 1979). College counselors and community counselors working with this population can support international students at the microsystem level by asking them to identify and deeply explore “safe” and “unsafe” relationships that exist within their college/university campus, neighborhood, and relevant religious group. Next, counselors can empower international students by framing their concerns as part of a larger systemic issue to minimize self-blame (i.e., seeing themselves as the cause of their challenges; Sue & Sue, 1990). Here, the focus is placed on empowering international students to engage in self-advocacy within the systems they occupy (Haskins & Singh, 2015). The reframe may also aid in enhancing the international student’s critical consciousness (Ratts, 2017; Ratts & Greenleaf, 2017) and help them shift their perspectives from self-blame to acknowledging the role(s) of external oppressive forces (e.g., racism, xenophobia, Sinophobia; Manzano et al., 2017). Indeed, engaging in the internalization of problems in response to stressors is prevalent among many international cultures (Wong et al., 2013).
Interventions at this level might involve the use of microinterventions (Sue et al., 2019) to empower international students. Sue et al. (2019) defined microinterventions as deeds and interactions that communicate affirmation and validation to targets of microaggressions. These interventions have the potential to enhance the psychological well-being and self-efficacy of the target and disarm the effects of microaggressions by challenging the perpetrator. Counselors can provide psychoeducation on microinterventions, using caution and clinical judgment to avoid further harm to the student. It is imperative that counselors recognize and educate the international student that it could be dangerous to employ microinterventions without understanding the specificities of the context. Sue et al. noted that the minoritized individual (target) employing microinterventions must be intentional about picking their battles, as endless responses to each encountered incident of microaggression can be damaging to the target’s well-being. The target should be aware of the context of the microaggression and modify their response as the situation requires. Given that racism and oppression permeate classroom spaces, college counselors can also provide opportunities for practicing microinterventions through role plays (Litam, 2020). One microintervention is making the “invisible” visible by responding to instances of racial discrimination on campus, making the offending party (e.g., domestic students, staff) aware of their offensive actions or words, and/or compelling them to consider their impact (Sue et al., 2019). Counselors may further guide international students in educating the offender (Sue et al., 2019). Litam (2020) noted that although it is of critical importance to avoid placing the onus of responsibility on minoritized individuals (e.g., international students) to educate and/or confront their offenders, when they do engage in thoughtful responses the opportunity to educate can result in positive changes and healthier relationships.
Finally, counselors can support international students to incorporate mindfulness and self-compassion as culturally sensitive tools to address the xenophobic experiences of COVID-19–related racial discrimination (Litam, 2020). Compassion meditation may help international students release their feelings of anger and intentionally cultivate experiences of self-compassion and positive regard toward self and others. Self-compassion may be cultivated by encouraging international students to attend to their immediate needs by remaining present and non-judgmental (Germer & Neff, 2015). Grounded in the Buddhist concept of loving-kindness, international students may be trained to pay attention to their somatic experiences with a non-judgmental curiosity. For instance, as these students confront chronic racism, they may benefit from opportunities to be kind to themselves. Counselors may also guide them to engage in mindful breathing to ground themselves in the face of chronic stress (Germer & Neff, 2015).
Additionally, empowering international students to cultivate a strong sense of ethnic identity may also represent an important strategy at this level. Extant research continues to identify the role of ethnic identity as a protective factor for experiences of racial discrimination (Carter et al., 2019; Chae & Foley, 2010; Choi et al., 2016; Tran & Sangalang, 2016), including experiences of COVID-19–related racial discrimination (Litam & Oh, in press).
Counselors working with international students at the mesosystem level may continue to strengthen the interventions at the microsystem level while exploring mental health stressors that may arise through interactions between the student and their peers and/or members of the college/university campus community. Counselors who interact with various social groups uniquely position themselves in ways that establish new relationships, building support with spiritual and religious leaders (Sue et al., 2019) and mid- and senior-level administrators who are then able to directly or indirectly support international students on and off campus (Mac et al., 2019).
Leveraging their network within the university system, college counselors can explore how faculty members, administrators, and staff may improve their cultural humility and competence by collaborating with them in efforts to support international students within the campus (Hook et al., 2013). For instance, faculty members and staff could be invited to on-campus ethnic interest groups, cultural festivals, or language clubs on a regular basis to immerse themselves in their students’ cultural practices. Additionally, many international students on campus occupy shared housing. College counselors can teach international students’ roommates, peers, and resident advisors to detect signs of distress and isolation. This can potentially help student leaders and other residents better support international students and promote wellness in the student body more broadly. Engaging the community in culturally relevant strategies for promoting the mental health of international students and recognizing their distress may help college counselors in early detection of distress for this community.
The exosystem level examines social settings that indirectly impact the student but in which the student has no direct impacts (e.g., local politics, medical and social services; Bronfenbrenner, 1979). Interventions at the exosystem level might examine how educational training grounded in Eurocentrism may further marginalize international students and negatively impact their academic standing and their overall mental health and well-being (George Mwangi et al., 2019; Ploner & Nada, 2020). Counselors working with international students at the exosystem level must shift their perspectives from interpersonal interventions toward a greater examination of systemic influences. Counselors may utilize the MSJCC (Ratts et al., 2015) to consider the intersecting ways in which the privileged and oppressed identities of international students uniquely influence their mental health experiences. A detailed description of how counselors can apply the MSJCC to counseling international students can be found in Kim et al. (2019).
College counselors working at the exosystem level must play an active role in advocating on behalf of international students by working to dismantle White supremacy in college/university counseling settings (Ratts, 2017) and academic settings (Haskins & Singh, 2015). Furthermore, counselors working at the exosystem level are called to advocate for inclusive spaces and educational curricula that incorporate diversity of thought and pedagogical practices that cater to all student groups. Other examples of exosystem-level advocacy include involvement with academic units, institutions, organizations such as NAFSA and the American College Personnel Association, and communities that indirectly impact international students (Manzano et al., 2017). Trainings for educators and staff at colleges/universities about the importance of dismantling systemic racism and facilitating anti-oppressive pedagogy may also be provided (Berlak, 2004).
Furthermore, community counselors working with this population may collaborate with various social groups (e.g., host families) to develop antiracist approaches that address internalized racism and White supremacy (Kendi, 2019; Singh, 2019). These collaborations may also aid in facilitating the help-seeking behavior of international students and countering the embedded stigma against seeking mental health support (Liu et al., 2020).
The macrosystem-level focus is on cultural norms, values, and laws that influence the international student without being directly influenced by the student (Bronfenbrenner, 1979). At this level, college counselors may collaborate with other health specialists (e.g., community mental health counselors, social workers, medical doctors) and explore how current U.S. political structures impact the mental health and well-being of international students. These alliances can help students as counselors engage in advocacy initiatives and tackle public policy on behalf of the student (Chan et al., 2019). For example, college counselors can engage in advocacy efforts similar to those that encouraged college and university administrators to oppose the ICE policy by President Trump that targeted international students.
In addition to seeking change to public policies that discriminate against international students, college counselors working at the macrosystem level can also advocate for equitable practices within college and university systems and promote an educational climate that celebrates international students on campuses. Forming alliances with stakeholders (e.g., administrators, legislators, legislative staff) who directly and indirectly impact cultural norms and values in society could also be a helpful strategy for counselors supporting international students at the macrosystem level (Mac et al., 2019). Similarly, community counselors can offer cultural sensitivity training programs to members of local government agencies (e.g., credit unions, DMV). Knowledge of how visa regulations and cultural norms operate can help state and national organizations better serve this population. Finally, platforms such as the National Association for College Admission Counseling and The Chronicle of Higher Education may offer unique spaces for collaboration among counselors, educators, and allies to advocate for this community.
The chronosystem encompasses all other societal systems that directly and indirectly impact the international student over time (e.g., federal employment policies; Bronfenbrenner, 1979). Interventions at the chronosystem level could address how the transition from an international student to worker in the United States (e.g., H-1B visa–holding professional) impacts how they are perceived by American society. For example, counselors can design programs that identify and address the needs of international students based on past and current sociopolitical events (e.g., 9/11 attacks, COVID-19 pandemic). Furthermore, college counselors may consider how these sociopolitical events might lead to disparaging attitudes toward international students and actively work to facilitate workshops, webinars, or trainings that identify and dispel harmful notions. Both college and community counselors must critically consider how systems continue to evolve over time (Chan et al., 2019). Therefore, they need to be actively attuned to the needs of international students, stay abreast of the current events that affect them, and actively participate in professional advocacy efforts across various systemic levels (e.g., institutional, state, national) to continue supporting this vulnerable community.
Using the search terms listed earlier, we completed an extensive review of the counseling literature. A paucity of empirical research exists in the counseling profession on international students’ mental health needs and experiences from a critical and systemic perspective. Empirical data can help counselors discern which types of interventions are most effective for international students within the counseling setting across various systems. In this article, we highlight that because of racial, linguistic, gender, and other differences within the international student community, an intersectional approach to inquiry is necessary. For instance, the experiences of a White, German, male international student will be vastly different from the experiences of a Black, Ghanaian, female student. Thus, inquiry on the experiences of this community must be positioned in the intersectionality framework (Crenshaw, 1989). Limited access to critical scholarship on the mental health experiences of international students within the counseling setting puts counselors at risk for retraumatizing their minoritized clients (Jones et al., 2017) through potential use of microaggressions and stereotypes, as shared by participants in the study by Liu et al. (2020). Thus, a tutorial stance grounded in cultural humility (Hook et al., 2013) and openness may be needed to build a safe and meaningful therapeutic relationship (Gonzalez et al., 2020). Future inquiries may help practitioners develop training modules and culturally responsive resources to improve their counseling skills and advocacy work with international students.
This article outlines a critical feminist and bioecological systems approach to supporting international students who are at higher risk for mental health distress because of xenophobic policies, racial discrimination, and systemic barriers. Discriminatory attitudes and behaviors toward international students have heightened during the current COVID-19 pandemic. Amidst this burgeoning crisis, counselors practicing in all settings are called to consider how each of these factors uniquely contribute to the mental health and overall well-being of this vulnerable population. Future research is needed to establish specific interventions that are most effective in mitigating the effects of pandemic-related stressors on the mental health of international students. Counselors are called to engage in advocacy efforts that dismantle systems of oppression at various levels, including within the community, in university/college settings, and in state and federal policies.
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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S Anandavalli, PhD, NCC, LPC-I, is an assistant professor at Southern Oregon University. John J. S. Harrichand, PhD, NCC, CCMHC, ACS, LPC, LMHC, is an assistant professor at State University of New York at Brockport. Stacey Diane Arañez Litam, PhD, NCC, CCMHC, LPCC, is an assistant professor at Cleveland State University. Correspondence may be addressed to S Anandavalli, Clinical Mental Health Counseling, Southern Oregon University, 1250 Siskiyou Blvd, Ashland, OR 97520, email@example.com.
Kristen Arla Langellier, Randall L. Astramovich, Elizabeth A. Doughty Horn
Counselors are frequently called upon to be advocates for their clients and, more broadly, to advocate for the counseling profession. However, many new counselors struggle with integrating advocacy work in their counseling practice. This article provides an overview of service learning and identifies ways counselor educators may foster advocacy skills among counselors-in-training through the use of planned service learning experiences in the counselor education curriculum. The authors then provide examples of service learning activities for use within the Council for Accreditation of Counseling and Related Educational Programs (CACREP) 2016 core curricular areas, including professional orientation and ethical practice, social and cultural diversity, career development, helping relationships, and group work.
Keywords: advocacy, service learning, counselor education, ACA, CACREP
University faculty members frequently include service learning experiences in the undergraduate curriculum as a means for helping prepare students to develop as community members through meaningful civic engagement experiences that are augmented with classroom education (Servaty-Seib & Tedrick Parikh, 2014; Stanton & Wagner, 2006). Unfortunately, service learning assignments tend to diminish significantly as students make the transition from undergraduate to graduate education (Jett & Delgado-Romero, 2009; Servaty-Seib & Tedrick Parikh, 2014; Stanton & Wagner, 2006). Much of the existing scholarly literature centers around the impact of service learning on students who are at a traditional undergraduate age (Jett & Delgado-Romero, 2009; Servaty-Seib & Tedrick Parikh, 2014). The lack of service learning opportunities in the graduate curriculum is surprising, given that service learning may help students develop a deeper sense of community, appreciate others’ perspectives, and identify avenues for contributing to social change (Cipolle, 2010).
Within graduate counselor training programs, counselor educators could more frequently utilize service learning projects (SLPs) in order to enhance knowledge of diverse community cultures among counselors-in-training (CITs) as well as provide CITs with opportunities to assess community needs and implement advocacy efforts. The counseling profession’s Multicultural and Social Justice Counseling Competencies (MSJCC), revised in 2016, states the importance of “integrating social justice advocacy into the various modalities of counseling” (Ratts et al., 2016, p. 31). In addition, the MSJCC posits that counselors and counselor educators conceptualize clients through a socioecological lens so as to understand the social structures affecting their world. Service learning curricula often include a social justice focus, which has been demonstrated to help students understand the structures in place that oppress others (Tinkler et al., 2015). With these guidelines in mind, the purpose of this article is to provide practical suggestions to help counselor educators infuse service learning into their curriculum, thus offering CITs more opportunities for personal and professional development.
Service learning was first introduced in the early 1900s as a method for fostering academic and social learning and advancements for students via community involvement (Barbee et al., 2003). Bringle and Hatcher (1995) defined service learning as
a credit-bearing, educational experience in which students a) participate in an organized service activity that meets identified community needs, and b) reflect on the service activity in such a way as to gain further understanding of course content, a broader appreciation of the discipline, and an enhanced sense of civic responsibility. (p. 112)
Since its inception, many disciplines have found service learning useful as a method of merging the academic with the practical; it has become popular with disciplines such as nursing (Backer Condon et al., 2015), teacher education (Tinkler et al., 2015), and public health (Sabo et al., 2015).
With respect to counselor education, there has been a diminutive amount of research related to the implementation and effectiveness of service learning. In 2009, Jett and Delgado-Romero described service learning as an area of developing research in counselor education, and this could still be said today. There is a paucity of literature regarding service learning in graduate education (Servaty-Seib & Tedrick Parikh, 2014) and, more specifically, within counselor education. Yet university faculty, particularly counselor educators, are tasked with the challenge of bridging academic theory and research with “real-world” experiences. Therefore, SLPs may serve as a method for students and faculty to connect with the community in which they live and beyond (Nikels et al., 2007).
After reviewing service learning literature, Dotson-Blake et al. (2010) determined successful SLPs contain five essential characteristics that contribute to the overall intention of service learning. They contended successful SLPs should be developed in concert with a community or professional partner, contain coherent and well-defined expectations, incorporate stakeholder support, consider students’ developmental levels, allow ample opportunity for reflective practices, and broaden or expand because of the impact of the project (Dotson-Blake et al., 2010). Focusing on the above underpinnings of successful SLPs could potentially assist counselor educators in the planning and implementation stages of these sorts of projects, as they can take time and considerable effort to develop.
Service Learning and Social Justice
According to Cipolle (2010), social justice and service learning are interrelated. She asserted that service learning and social justice need to be considered together so as to accomplish a larger goal of connection with the community. An additional component to service learning is the development of critical consciousness. Students engaging in service learning as a means of social justice may gain compassion and understanding from their participation (Cipolle, 2010). A by-product of service learning with a social justice focus may be the development of self-awareness through students’ opportunities to see for themselves how others live their lives; perhaps students will also see the impact of the dominant culture (Cipolle, 2010). Self-awareness is a key component of the 2016 MSJCC (Ratts et al., 2016) and is found throughout the Council for Accreditation of Counseling and Related Educational Programs (CACREP) 2016 Standards (CACREP, 2015). Additionally, the ACA Code of Ethics asserts that counselors should ascribe to self-awareness to maintain ethical practice and reflection (American Counseling Association [ACA], 2014).
Service Learning Versus Community Service
An important distinction between community service and service learning lies within the beneficiaries of each. Within community service, the beneficiaries are those receiving the service. Service learning posits a reciprocal model, with both the recipient of service and student benefitting from the project (Blankson et al., 2015). Thus, SLPs provide students with opportunities to be exposed to issues of social justice that may foster empathy and cultural self-awareness. Students can benefit from service learning as it may assist them in developing increased compassion for others (George, 2015). With the continued focus on social justice within many disciplines, SLPs may provide another avenue for counselor educators to help students more fully understand the diverse needs of their communities and advocate for the underserved.
Throughout participation in an SLP, and at the completion, students are encouraged to apply critical thinking to their efforts and reflect on progress, barriers, and benefits (Blankson et al., 2015). For successful service learning to occur, projects should be connected to specific course objectives. Such a curricular emphasis is not generally a component of community service initiatives. By combining student projects and course material, instructors are able to help students solidify course material into practical applications (McDonald & Dominguez, 2015). This experiential avenue may appeal to non-traditional learners and provide more integration of material than didactic coursework alone (Currie-Mueller & Littlefield, 2018).
Effects of Service Learning
Cipolle (2010) reported that students participating in early service learning received numerous benefits, including having higher self-confidence, feeling empowered, gaining self-awareness, developing patience and compassion, recognizing their privilege, and developing a connection and commitment to their community. All of these outcomes are consistent with the aims and goals of standards, competencies, and codes of ethics within the counseling profession (ACA, 2014; CACREP, 2015; Ratts et al., 2016).
Scott and Graham (2015) reported an increase in empathy and community engagement for school-age children when participating in service learning. They also reported that several previous works measured similar favorable effects among high school– and college-age individuals. Because of these overlapping desired effects and the need to incorporate social justice throughout the curriculum, service learning would fit well into current models of counselor education.
Service Learning Efforts in Counselor Education
The ACA Code of Ethics (2014) calls upon professional counselors to donate their time to services for which they receive little to no financial compensation. The incorporation of SLPs could provide an opportunity to fulfill this ethical obligation while training students and connecting with the community. A dearth of literature exists as to specific counselor education service learning efforts. Of the few results, many are focused on pre-practicum level SLPs (Barbee et al., 2003; Jett & Delgado-Romero, 2009), pedagogical tools woven into the multicultural and diversity-based courses (Burnett et al., 2004; Nikels et al., 2007), and group leadership training (Bjornestad et al., 2016; Midgett et al., 2016). Alvarado and Gonzalez (2013) studied the impact of an SLP on pre-practicum–level counseling students and found that students reported an increase in their confidence in using the core counseling skills and a deeper connection with the community outside of the university setting. Havlik et al. (2016) explored the effect SLPs had on CITs and found similar themes to Alvarado and Gonzalez, particularly that of raised levels of confidence in the ability to use the core counseling skills.
In other counselor education–related studies, researchers also reported positive impacts of service learning. One such impact was that of raised student self-efficacy (Barbee et al., 2003; Jett & Delgado-Romero, 2009; Murray et al., 2006). An added and practical benefit for students has also been a greater understanding and familiarity of the roles and settings of professional counselors and a deepened understanding of counselors’ roles within professional agencies. Students were able to examine their own professional interests prior to practicum work and participate in valuable networking experiences with other professionals (Jett & Delgado-Romero, 2009).
An increased compassion for the population with whom they work has been reported (Arnold & McMurtery, 2011) as a result of service learning. Burnett et al. (2005) reported increased counselor self-awareness, which is an important component of counselor education, regardless of delivery method, program accreditation, or instructor pedagogy. They also reported a component of a successful service learning course to be peer-learning. Peer-learning involves the giving and receiving of feedback, and this provides a foundation for experiences of group supervision feedback later in counseling programs (Burnett et al., 2005). A frequent reported result of participation in service learning has been increased multicultural competence and social justice awareness on the part of the student (Burnett et al., 2004; Lee & Kelley Petersen, 2018; Lee & McAdams, 2019; Shannonhouse et al., 2018). In short, the incorporation of SLPs would benefit counselor educators in developing desired qualities in beginning counselors while giving them opportunities to network and more fully integrate material.
Integrating Service Learning Into Counselor Education
Freire (2000) espoused that education should inspire students to become active and engaged members of the classroom in order to develop a deeper critical consciousness of society. Keeping Freire’s goal in mind, counselor educators could utilize service learning to bridge the divide that exists between the “ivory tower” and communities outside of academia. Counselors are called to apply their theoretical knowledge to real-world clients and to be advocates for those whose voices are silenced because of various forms of oppression (ACA, 2014; CACREP, 2015; Ratts et al., 2016). Through participation in SLPs, students are able to see firsthand the effects of oppression and assist with creating solutions; often, the projects chosen contain an element of social justice (George, 2015). Furthermore, SLPs woven into coursework may provide the opportunity for students to begin finding their voices as advocates and activists in a supportive environment, where peers are available to assist with potential problems that may arise.
By encouraging CITs to participate in SLPs earlier and often within their graduate education, students may have more opportunities to engage with diverse populations and to experience community environments and sociopolitical influences faced by different groups. The focus of clinical work during the practicum and internship phases of counselor education typically emphasizes counselor skill development and client progress rather than community-focused perspectives (Barbee et al., 2003; Jett & Delgado-Romero, 2009). Thus, by incorporating SLPs into regular coursework, students may feel freer to engage holistically in a community system rather than focus narrowly on their own counseling skill development and individual client progress. For all SLPs, there is the potential for students to experience the project components as challenging to complete. In this situation, students may be redirected to identify and analyze barriers to the success of the project and to identify strategies for eliminating those barriers.
Gehlert et al. (2014) argued that SLPs can also serve as potential gatekeeping tools. They posited that by engaging with individuals outside of the classroom experience, especially earlier than the practicum stage, students might decide for themselves that the counseling profession is not the right choice for their career (Gehlert et al., 2014). They further contended that utilizing SLPs early in students’ programs of study will allow the opportunity for faculty to identify students who might be in need of remediation plans before they are working with clients (Gehlert et al., 2014).
Counselors are urged to be advocates for the profession and for clients (ACA, 2014). Service learning may function as a natural initiation into that identity (Manis, 2012; Toporek & Worthington, 2014) and could possibly provide a bridge between an identity as a counselor and that of a counselor advocate. Another potential benefit of service learning is that students may be able to gain knowledge as to the realities of the profession beyond specific contact hour requirements to satisfy internship and licensure requirements. This could prove helpful as a gatekeeping tool as well. Students who find themselves disliking significant aspects of the profession might choose to leave the program without requiring faculty intervention.
Experiences of SLPs can be distilled into poster presentations or conference presentations. In this context, SLPs benefit both CITs and counselor educators, as professional development can occur for both. For students, conferences can be valuable networking opportunities, and for counselor educators, conference-related activities fall under required professional development (ACA, 2014; CACREP, 2015). Experiences could also serve as the foundation for manuscripts and research projects, both of which are considered professional development.
Service Learning Opportunities Within Specific Counseling Content Areas
CACREP (2015) provides counselor educators with standards for training that can be used to facilitate course development, learning objectives, and class assignments. Several core content areas within a CACREP-aligned counseling curriculum may offer instructors and students the chance to engage in SLPs. Because little information currently exists regarding best practices for service learning within counselor education, the authors created example SLPs that are based on CACREP standards and rooted in the relevant content area literature. These are designed to facilitate the development of advocacy skills in a variety of environments. It should be noted that with any SLP, it is important for counselor educators to engage in continued monitoring of projects and student placements. Given that SLPs provide a reciprocal benefit for both students and the community, it is important to ensure everyone involved is experiencing ongoing added value. Therefore, counselor educators are encouraged to create and maintain relationships with stakeholders for feedback throughout the SLP and to make adjustments as necessary.
Professional Orientation and Ethical Practice
Licensure remains an important topic within the counseling profession (Bergman, 2013; Bobby, 2013) and professional counselors are now able to obtain licensure in all states (Bergman, 2013; Urofsky, 2013). In order to become more familiar with state licensure policies and procedures, an SLP might involve student interviews with a member of the state licensure board and reflection upon that experience through a written journal entry. Questions posed to the board member could range from the practical aspects of obtaining a license in their state to the broader implications of ethical issues the board encounters. Student findings could then be utilized to develop a project involving the entire class in which students brainstorm ideas about what assistance the board might need in terms of outreach or advocacy. Examples could include barriers to licensure because of cost or English as a second language (making the testing aspect of obtaining licensure difficult). Students and faculty could use class time deciding what action to take and then implement and assess their plan.
Another example of an SLP that falls under this core content area is for students to volunteer time (e.g., 6 hours or more over a semester) assisting their state branch of ACA. An important aspect of the profession of counseling is involvement with relevant policy and legislation (Bergman, 2013). Students interested in getting involved in this area could spend time working with the lobbyist for their state’s ACA branch (provided the state has retained a lobbyist) in order to assist them in advocating for the profession. Simple tasks such as assisting with office work can be of significant help to one working in a high-stress position and can prepare students for the realities of clinical work. State and federal government have a significant role in shaping the profession (Bergman, 2013), and because of this, counselor educators can utilize service learning in order to inspire students to become involved early in their careers.
Should the state ACA branch not have retained a lobbyist, students can work with branch leadership in order to determine barriers. Perhaps costs are prohibitive, in which case students could help with fundraising efforts and outreach. Encouraging master’s students to take interest in policy and legislation pertaining to the profession will give them the foundation for making meaningful change and assisting with social justice efforts (Cipolle, 2010; Bergman, 2013).
Social and Cultural Diversity
Much of the existing literature regarding service learning and counselor education focuses on social and cultural diversity with regards to SLPs (Burnett et al., 2004). Philosophically, SLPs align with the aims and scope of the MSJCC (Ratts et al., 2016). Frequently, course assignments contain a cultural immersion project in order for counselors to encounter experiences in which their personal values might cause a conflict when working with clients (Burnett et al., 2004; Canfield et al., 2009). Service learning experiences could easily augment the student learning process within multicultural or diversity courses by helping students experience cultural immersion, which may foster greater compassion, empathy, and cultural sensitivity (Cipolle, 2010; Burnett et al., 2004).
One possibility for a social and cultural diversity–focused SLP would involve students working at a shelter for homeless populations or a center for refugees. Students could also find an organization that serves a minority or oppressed population and partner with them to help fill a need they are experiencing. Students would therefore gain experience working with people from groups with whom they may have limited prior experience. This can assist with students identifying their own privileges prior to working in the counseling setting. Ideally, students would contact the shelter or center at the start of the semester in order to ascertain the exact needs of the agency.
An additional SLP could focus on assisting an organization that advocates for minority or oppressed populations. This also emphasizes gaining experience with diverse populations; however, students would have more freedom in choosing the specific population and could gain more experience in understanding the systems involved in advocacy work. Ideally, the instructor would encourage students to choose organizations in which the student is challenged by their privileges (e.g., not being identified as a member of the population served). Through this project, students have the opportunity to work with a wider variety of individuals and help to bring about social change via their specific project goals. For instance, students could choose a women’s health center that has experienced a decline in attendance. The students might investigate and discover a particular city bus route was discontinued, making transportation to the health center difficult for residents. Students might then partner with various organizations with van access (such as churches) and raise money for weekly transportation in and out of the area.
Within the career development area of the CACREP core curriculum, students have the possibility of learning about their own careers and the impact careers have on the lives of clients. Examples of SLPs can include opportunities for students to immerse themselves within various aspects of career development. Several SLPs could come from partnering with a local employment agency. Students could discover barriers to employment for members of the local community and implement a project to alleviate some of those barriers. For example, students might discover a lack of late-night childcare in their community, which affects those working during the evening and night. They might implement a project in which university students provide childcare for a reasonable cost to the parents, making finding employment easier. If liability issues make this too difficult, students could focus their attention on fundraising to hire more qualified individuals to provide the childcare.
As mental health and wellness are primary foci of professional counselors (ACA, 2014; CACREP, 2015), a second potential SLP assignment related to career development could be for students to partner with a local business and provide mental health and wellness screenings, and education via seminars or workshops. Ideally, students would familiarize themselves with the company insurance (or lack thereof) and prepare referrals and resources accordingly. Workshops and seminars could be an avenue for educating employees and the community at large about wellness, prevention, and good mental health. These could be delivered via “brown bag lunches” or more formal trainings for employees.
As CITs progress though counselor education programs, it might be helpful for them to discover new ways to employ their skills in helping relationships outside of counseling sessions. Much of the aforementioned scholarship exploring service learning within counselor education discovered an increase in self-efficacy with respect to core counseling skills as a result of participating in SLPs (Alvarado & Gonzalez, 2013; Havlik et al., 2016). An SLP suitable for this core curriculum could be to partner with a suicide prevention agency and provide assistance where needed. For example, students might work on a suicide hotline or provide referrals for people in distress, utilizing their relationship-building skills and reflective listening while learning about suicide assessment or prevention efforts within the community. Of course, it is important to consider students’ level of development and readiness to work with individuals who are suicidal. Counselor educators should ensure there are appropriate supports and supervision for students in these settings. A related project could be for school counseling students to partner with such an organization to create a developmentally appropriate suicide education presentation for high school–age children and deliver it to area schools.
Another SLP focused on the helping relationship might involve students seeking non-counseling placements at local counseling agencies or private practice settings. Ideally, students would have the opportunity to immerse themselves in many elements of practice without having a focus on accruing direct client contact hours. Spending time at an agency before practice might provide students with opportunities to learn many aspects of the profession and the operations of the agency, which in turn could help students decide within which settings they would like to work. This project might also help inform students about potential barriers clients might face in accessing services. They could develop a plan for removing the barriers, which might include identifying potential sources of funding for the project (e.g., grants, scholarships, community donations) and providing an outline of how to access this funding. Another potential benefit to this project is that it could provide students with the opportunity to network within the local counseling community and connect agencies with potential interns.
SLPs that correspond to group work can be similar to those under the helping relationships core curriculum. For example, students could partner with a local counseling agency that provides group counseling services. Students could determine if clients encounter any barriers to receiving group counseling and implement a plan for eliminating the barrier(s). A further example is perhaps if the agency has a group in which they would like to see more culturally relevant topics used in order to attract a more diverse group of clients. Students partnering with this agency could perform outreach to discover what clients would like to see at the group and any barriers, such as transportation, to attending this group. Another possibility for an SLP is for students to facilitate a group counseling experience for an agency or shelter for no cost to those participating in the group.
SLPs have the potential to enhance the learning experiences of students within graduate counselor education programs. Although not previously emphasized within counselor training, SLPs may be developed and implemented within a variety of core counseling content areas as suggested by CACREP (2015). From an advocacy and social justice perspective, SLPs also may provide students with multiple opportunities to experience the needs of clients and identify barriers to providing counseling services with diverse client populations. Ultimately, by utilizing SLPs, counselor educators can help foster CITs’ advocacy and social justice identities, preparing them for work as responsible citizens and effective counselors.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Kristen Arla Langellier, PhD, NCC, is an assistant professor at the University of South Dakota. Randall L. Astramovich, PhD, LCPC, is an associate professor at Idaho State University. Elizabeth A. Doughty Horn, PhD, LCPC, is a professor at Idaho State University. Correspondence may be addressed to Kristen Langellier, Division of Counseling and Psychology in Education, University of South Dakota, 414 E. Clark St., Vermillion, SD 57069, firstname.lastname@example.org.
Ariann Evans Robino
Explanations of compassion fatigue generally consider the client–counselor relationship as the primary source of challenges to wellness. Because of the nature of the current sociopolitical climate and the increased exposure through media, the counseling profession should consider expanding the influences on compassion fatigue related to current events. This article introduces the concept of global compassion fatigue (GCF), a phenomenon that provides an opportunity for counselor self-awareness. Implications for adopting GCF into the counselor impairment literature include understanding how global events impact counselor development and clinical practice as well as the importance of maintaining a wellness lifestyle to protect against its effects. Counselors’ involvement in advocacy and social justice are also explored as contributors to GCF.
Keywords: global compassion fatigue, counselor impairment, advocacy, self-awareness, wellness
Counselors and counselors-in-training (CITs) feel the weight of societal stressors. According to the ACA Code of Ethics, “promoting social justice” (American Counseling Association [ACA], 2014, p. 3) is a core value of the counseling profession. Furthermore, because of its impact on the profession, scholars have declared social justice as the fifth force in counseling (Ratts, 2009; Ratts, D’Andrea, & Arredondo, 2004). Representatives from ACA have acted in accordance by addressing the federal government’s recent prohibition of specific language associated with diverse populations (Yep, 2017) as well as releasing a statement of support shortly after the 2016 presidential election calling on all counselors to remain strong in their beliefs and actively assist those in need (Roland, 2016). Similarly, the closing keynote speaker at ACA’s Illuminate Symposium on June 10, 2017, Dr. Cheryl Holcomb-McCoy, encouraged attendees to take action against human rights offenses through vocal opposition in multiple settings, including social media (Meyers, 2017). These positions demonstrate the desired role of counselors to engage in advocacy and activism for global issues.
Natural disasters, threats to civil rights, violence, terrorist attacks, and animal welfare concerns are simply a few of the powerful issues that humans face as highly social and emotional beings. Although advocacy is one avenue of handling the emotional unrest related to these events, the complex nature of counselors’ personal and professional identities presents an invitation to consider these sensitive issues currently faced by society. Professional counselor identity allows counselors to make meaning of their work during these times of strong emotion (Solomon, 2007). Considering how these events affect both counselors’ and CITs’ personal lives and clinical practice produces opportunities for counselor professional development and greater self-awareness. The purpose of this article is to explore global compassion fatigue (GCF), a phenomenon related to the human condition and how global events impact professional counselors and other helpers. This article begins with a review of current counselor impairment concepts as well as the role of wellness in managing these conditions. Then, the reader is introduced to GCF and how a review of the literature supports the examination of this new concept. Next, I provide a detailed conceptualization of the phenomenon and implications for the field. Finally, suggestions for future research are provided.
Understanding Compassion Fatigue
Compassion fatigue research spans the literature of multiple disciplines, including nursing, social work, and counseling (Compton, Todd, & Schoenberg, 2017; Lynch & Lobo, 2012; Sorenson, Bolick, Wright, & Hamilton, 2016). Counselors typically understand compassion fatigue as an event occurring as a result of counselor–client interaction. Charles Figley (1995) first defined the concept of compassion fatigue as “a state of exhaustion and dysfunction—biologically, psychologically, and socially—a result of prolonged exposure to companion stress and all that it evokes” (p. 253) and conceptualized it as a response to the emotional demands of hearing and witnessing stories of pain and suffering. Symptoms of compassion fatigue include re-experiencing the client’s traumatic event, avoidance of reminders of the event and/or feeling numb to those reminders, and persistent arousal (Figley, 1995). Researchers carefully note the differences between compassion fatigue, vicarious traumatization, and burnout (Lawson & Venart, 2005; Meadors, Lamson, Swanson, White, & Sira, 2010). Vicarious traumatization, defined as a significant altering of cognitive schemas and a disruption of an individual’s sense of identity, worldview, and meaning, occurs as a result of empathic engagement with the traumatic experiences of a client (McCann & Pearlman, 1990). Vicarious traumatization symptoms involve a more covert change in thought and cognitive schema rather than an observable experiencing of symptomatology (Jenkins & Baird, 2002). Burnout is a process that occurs because of occupational stressors such as high caseloads, low morale, and minimal support (Maslach & Jackson, 1981). It is associated with emotional exhaustion, strain, and overload in addition to a reduction in personal accomplishment and job satisfaction (Maslach, 1982). Counselors are more likely to experience compassion fatigue, vicarious traumatization, and burnout when they have a previous history of personal trauma (Baird & Kracen, 2006), high emotional involvement with clients (Adams, Boscarino, & Figley, 2006), fewer perceived coping mechanisms (Baird & Kracen, 2006), and lower self-awareness (P. Clark, 2009). However, the goal of this article is to expand upon the phenomenon of compassion fatigue as distinguished from these other explanations of impairment to understand better how global events outside of the counselor–client dyad impact counselors. Although other impairment concepts hold value and applicability to counselors, compassion fatigue and its relationship to emotional suffering as a result of a desire to help others most closely aligns with the concept presented in this article. When considered in the context of counselors, an awareness of compassion fatigue, its effects, and how to mitigate those effects is vital for client welfare.
Counselor Impairment and Wellness
According to the ACA Code of Ethics, counselors should “monitor themselves for signs of impairment from their own physical, mental, or emotional problems” (ACA, 2014, p. 9). The ACA Code of Ethics dedicates an entire section to counselor impairment (C.2.g.), which states that, in the interest of client protection, counselors should cease providing services while impaired, seek assistance to solve issues of impairment, and assist colleagues and supervisors in recognizing and rectifying their own impairment (ACA, 2014). When counselors are impaired, it can result in significant harm to clients through an interference with the counseling process, trust violations, and ethical breaches (Lawson, Venart, Hazler, & Kottler, 2007). Adopting an alternative lens for viewing the impairment literature presents an opportunity for counselors to monitor themselves and others for potential issues as indicated by the ACA Code of Ethics (ACA, 2014). In addition, the ACA Code of Ethics guides counselors to “engage in self-care activities to maintain and promote their own emotional, physical, mental, and spiritual well-being to meet their professional responsibilities” (ACA, 2014, p. 8). As self-advocacy for wellness can promote better professional practice within the counseling community (Dang & Sangganjanavanich, 2015), counselors are encouraged to avoid and rectify issues of impairment through positive, health-promoting strategies.
Recognizing this area of need within the profession, ACA established the Taskforce on Counselor Wellness and Impairment in 2003 to address the needs of impaired counselors (Lawson & Venart, 2005). The taskforce identified goals for education for counselors on impairment and how to prevent it, securing treatment for impaired counselors, teaching self-care strategies, and advocating within the organization and at both the state and national levels to address issues associated with impairment. Although the taskforce focused on the broader topic of impairment, compassion fatigue remains a component of this experience. The creation, cultivation, and maintenance of a wellness lifestyle is a primary means of addressing and rectifying counselor impairment and compassion fatigue (Lawson & Venart, 2005).
Wellness is defined as “a way of life oriented toward optimal health and well-being in which body, mind, and spirit are integrated by the individual to live life more fully” (Myers, Sweeney, & Witmer, 2000, p. 252). Wellness and prevention are core components of counselors’ professional identities (Mellin, Hunt, & Nichols, 2011). As a result, researchers have studied the benefits of wellness strategies for counselors (Cummins, Massey, & Jones, 2007), counselor educators (Wester, Trepal, & Myers, 2009), and CITs (Yager & Tovar-Blank, 2007). Additionally, Figley (1995) specifically identified poor self-care as a primary risk factor for experiencing compassion fatigue, and Chi Sigma Iota’s (CSI; n.d.) advocacy themes, specifically Theme 6, outline the need for advocacy related to prevention and wellness for clients and counselors (Lee, 2012). The development of a taskforce, the extensive literature associated with compassion fatigue and wellness, and CSI’s identification of wellness as an area of advocacy indicate a clear relationship between counselor experience and counselor practice. Based on previous research, ACA’s stance on counselor self-care, and humans’ innate desire to engage in complex processes to achieve optimal functioning and well-being, it is beneficial for counselors to consider a new phenomenon related to their consistent exposure to global issues through media and social media. Counselors currently conceptualize compassion fatigue as a linear process occurring as a result of the cumulative direct exposure to clients’ distressing experiences. This article presents an expanded perspective on counselor compassion fatigue occurring as a result of exposure to current events and issues. Furthermore, this article offers a language for this experience as well as a conceptualization of the phenomenon.
I suggest the term global compassion fatigue to describe the process by which an individual experiences extreme preoccupation and tension as a result of concern for those affected by global events without direct exposure to their traumas through clinical intervention. GCF requires examining compassion fatigue outside of client-specific experiences and within a larger context. This invites counselors and CITs to explore how they are human and existing in a conflicted, polarized, and oftentimes troubling world.
Figure 1 provides a visual depiction of these constructs. After exposure to a traumatic global event, humans experience an acute stress-related psychological response (Holman, Garfin, & Silver, 2013); for counselors this may manifest as GCF because of their foundational helping skills rooted in the ability to feel and exhibit empathy for the issues faced by others (A. J. Clark, 2010). Once this response occurs, counselors can utilize wellness and self-care strategies and engage in social justice advocacy efforts as deterrents to GCF. If they bypass these methods, they might experience the extreme preoccupation and tension that are indicators of GCF. However, counselors can interrupt and manage their GCF by moving to wellness and advocacy strategies.
Figure 1. Process of GCF. After media exposure to a global event and engaging in an emotional response, counselors can immediately experience GCF. Wellness and advocacy are two methods of either addressing GCF after experiencing it or through prevention to deter the experience.
GCF differs from vicarious traumatization in that it does not denote permanent change in cognitive schema; rather, a counselor can experience GCF transiently and in response to significant global and communal events. Counselors experiencing GCF do so outside of clients’ presenting problems. Although no current counseling literature describes this phenomenon, Stebnicki (2007) proposed the concept of empathy fatigue, which “results from a state of emotional, mental, physical, and occupational exhaustion that occurs as the counselors’ own wounds are continually revisited by their clients’ life stories of chronic illness, disability, trauma, grief and loss” (p. 318). Whereas GCF does bear similarity to empathy fatigue, empathy fatigue remains related to an occurrence resulting from direct clinical exposure (Stebnicki, 2007), and GCF involves counselor introspection unrelated to session content. Relatedly, Bayne and Hays (2017) recently conducted a study to conceptualize the conditions of empathy within the counseling process. They developed an exploratory model of counselor empathy that acknowledges the multidimensionality of the empathic process, including the variables associated with counselor impairment. GCF proposes that counselors’ intense emotional experiences related to global concerns are associated with empathy and a desire to help those directly affected. Current events that may cause a counselor to experience GCF include politics, natural disasters, violence (including mass shootings), terrorist attacks, threats to human rights, and animal abuse.
Compassion fatigue research is the best point of reference when considering the experience of GCF. Compassion fatigue manifests through physical, psychological, spiritual, and social symptoms (Lynch & Lobo, 2012), and counselors experiencing GCF also can exhibit these symptoms. However, counselors must consider the source of their feelings of fatigue. For example, Coetzee and Klopper (2010) noted, “compassion fatigue is caused by the prolonged, intense, and continuous care of patients, use of self, and exposure to stress” (p. 239). I suggest that GCF involves a similar experience, although as a result of continuous concern for other beings, a desire to help recover from or solve the issues affecting those beings, and repeated exposure to current events harming individuals on a large scale. Additionally, ACA’s Advocacy Competencies call for professional counselors to engage in systemic and sociopolitical advocacy on a continuum ranging from the microlevel (i.e., the individual) to the macrolevel (i.e., the public; Lewis, Arnold, House, & Toporek, 2003). Therefore, it is a counselor’s duty to remain aware of systemic, environmental, and political factors impacting clients in addition to immersing themselves in advocacy and mechanisms for change. Such actions may leave counselors susceptible to impairment in response to global issues, although moving from awareness to action also can help prevent or mitigate GCF.
Researchers have explored the effects of distressing events on helping professionals. Early research described the relationship between clergy members’ compassion fatigue and their time spent with trauma victims following the September 11th terrorist attacks (Flannelly, Roberts, & Weaver, 2005). Counselors responding after a natural disaster (Lambert & Lawson, 2013) and trauma counselors (Sansbury, Graves, & Scott, 2015) are populations often researched in the compassion fatigue literature. For example, Day, Lawson, and Burge (2017) reported the results of a qualitative research study exploring compassion fatigue and shared trauma in clinicians providing services after the shootings at Virginia Tech in 2007. Day et al. raised an interesting point between a counselor’s direct and indirect exposure to global events as well as the level of impairment resulting from the experience. Given the possibility that unresolved trauma can cause issues in functioning, direct exposure to an event removes the possibility that a counselor is experiencing GCF. This shared trauma may result in similar symptomatology, but these symptoms are attributed to the commonality of the trauma experience (Figley Institute, 2012).
From a different framework, researchers have explored the experiences of non-counselors when exposed indirectly to traumatic global events. Although many Americans were not in New York at the time of the September 11th attacks, nor were they likely to have known someone associated with the attacks, the stress of the event was felt across the country in the form of trauma symptoms (Schuster et al., 2001). Individuals living in Britain also experienced psychological changes as a result of the vicarious media exposure to these terror attacks on America (Linley, Joseph, Cooper, Harris, & Meyer, 2003). Similarly, college students at a separate university described an increase in acute stress symptoms as they learned about the shootings at Virginia Tech on television (Fallahi & Lesik, 2009). This research indicates that individuals can experience emotional duress in response to indirect exposure to global or national issues. Ultimately, it is important to remember that, despite extensive training and experience, counselors are humans navigating a society that can upset them in various ways. GCF awareness furthers counselor insight and promotes opportunities for evaluating self-care, wellness, and efficacy under these conditions. Such awareness requires an understanding of the role media plays in individuals’ experiencing of traumatic global events.
The Impact of Media
Previous researchers evaluated the impact of television viewing on an individual’s stress symptoms and levels of vicarious exposure (Fallahi & Lesik, 2009; Linley et al., 2003), suggesting that the role of technology can significantly affect a counselor’s ability to create boundaries and step away from the tragic circumstances occurring in the world around them. With 62% of adults obtaining their news from social media sites in 2016, an increase from 49% in 2012 (Gottfried & Shearer, 2016), it is clear that regular social media use can result in high levels of exposure to distressing news content. Additionally, four out of five adults in the United States reported constantly “checking” their cellular phones for emails, text messages, and social media (American Psychological Association, 2017). This same survey also described higher stress levels in the “constant checker” population than those using technology less frequently.
Researchers have discovered a link between emotional well-being and use of television media. Schlenger et al. (2002) found a statistically significant relationship between the levels of post-traumatic stress disorder symptoms and the numbers of hours spent watching television coverage of the September 11th terrorist attacks when assessing the psychological reactions of 2,273 adults residing in major metropolitan cities in the United States one to two months after the attacks. Fallahi and Lesik (2009) also identified a problematic association between indirect exposure to a tragic event through news media sources and symptoms of acute stress disorder.
Therefore, if a counselor or CIT is particularly sensitive to the content to which they are exposed through the media, they increase their risk of experiencing GCF. Conversely, social media also might provide an opportunity for community and connection in the face of global issues. The idea of community is no longer constrained within the bounds of physical associations; rather, the internet provides access to distant communities and relationships (Gruzd, Wellman, & Takhteyev, 2011). Supporters and activists involved in the Black Lives Matter movement are an example of such a community. Black Lives Matter erupted on social media as a Twitter hashtag created to raise awareness for and demonstrate protest against police brutality on members of the Black community (Petersen-Smith, 2015). Through this online movement, individuals were able to exhibit solidarity and take a stand against racism toward Black people with their use of social media (Schuschke & Tynes, 2016). Similarly, the #MeToo internet-based movement brought attention to women’s rights and sexual violence (Hostler & O’Neil, 2018), and social media platforms also provide a method of addressing the stigma of mental health and addiction (de la Cretaz, 2017).
ACA has an active social media presence through online pages and forums on their website, Facebook, Twitter, and LinkedIn (ACA, 2017). The ACA Code of Ethics (ACA, 2014) states that counselors will use social media only when it is in the best interest of the client while protecting their identity and well-being (Section H). This is another example in which a position is based on a situation specifically involving the client and counselor. Although researchers have explored the role of social media in counselor education (Tillman, Dinsmore, Chasek, & Hof, 2013) and recommendations have been made for using social media ethically in clinical practice (Giota & Kleftaras, 2014), researchers have yet to explore how social media affects practicing counselors on an emotional level. Adopting GCF into the counselor impairment literature would suggest a need for ACA to also establish recommendations for counselors’ social media use and how excessive exposure to global events can affect their work as counselors.
A New Perspective
As social beings dependent upon one another for survival, humans have an evolutionary and biological drive to feel connected and invested in others. Specifically, humans are interested in the welfare of others on a neurological level (Lieberman, 2013). Counselors and CITs can feel a need to help others based on evolutionary compulsions rooted in social psychology. However, they also can feel this drive to an amplified extent because of their consistent demonstration and use of empathy, a foundational helping skill that allows counselors to “enter the client’s phenomenal world, to experience the client’s world as it were your own without ever losing the ‘as if’ quality” (Rogers, 1961, p. 284). Although all humans are susceptible to experiencing fatigue as a result of high exposure to global issues through media, not all humans work in a helping profession based in the empathic experience. Therefore, similar to the need for counselors to monitor themselves for impairment as a result of direct engagement with clients’ presenting issues, counselors also need to monitor for impairment from global issues. Regardless of continuous exposure to distressing global events, counselors continue to help others on a consistent basis. This indicates a critical need for counselors to understand their relationship to social media and the global events to which they experience an emotional response.
Symptoms of GCF can manifest similarly to traditional compassion fatigue. These symptoms can include emotional and physical exhaustion associated with care for others, desensitization to stories and experiences, poorer quality of care, feelings of depression or anxiety, increased stress, difficulty concentrating, and preoccupation (Figley Institute, 2012). Ultimately, it is the responsibility of the counselor to understand the source of these symptoms. Unlike counselors’ direct work with clients in which there may be greater opportunities to assist in managing or addressing a pain-inducing problem, emotional and cognitive responses to global issues present a different type of challenge. Managing issues in which a person may perceive little control and direct influence can cause responses such as rumination (Nolen-Hoeksma, Wisco, & Lyubomirsky, 2008) and fear (Pain & Smith, 2008). Although counselors can experience these feelings regarding clients (Sansbury et al., 2015), there are greater opportunities for direct interaction with the client needing assistance. In most cases, counselors are unable to directly impact the people involved in the global events to which they are continuously exposed through media and social media. Optimal human functioning involves integration of the mind, body, and spirit (Myers et al., 2000). GCF can impact this integration when counselors are unable to live fully through the exhaustion of exposure to global events. Wellness strategies and forms of advocacy can prevent or rectify these experiences. Myers et al. (2000) acknowledged that “global events, whether of natural (e.g., floods, famines) or human (e.g., wars) origin, have an impact on the life forces and life tasks depicted in [wellness models]” (p. 252). In addition, advocacy in the wake of social events can provide feelings of efficacy and social connection (Scott & Maryman, 2016). This new perspective provides implications for the profession of counseling, including recommendations, cultural considerations, and areas of future research.
Implications for Counselors
In a “plugged-in” society, it is possible to become overwhelmed with the daily stream of news and information. Additionally, counselors can be at higher risk of experiencing impairment because of their empathic nature (Figley, 1995) and ethical duty to engage in social justice for causes that improve equity for individuals and groups (ACA, 2014). As leaders and advocates, GCF may be present in counselors’ daily clinical work. Licensed counselors in private practice may not be receiving ongoing supervision (Bernard & Goodyear; 2014); therefore, no external individual is monitoring how they are managing GCF and its effects. Counselors outside of supervision must exercise great care to practice self-awareness and approach others for assistance. Furthermore, counselors in high-volume settings often work with large caseloads that present with complex issues (Belling et al., 2011; Lombardo, 2018), and it may be easy for them to ignore their own needs while addressing the needs of others. Given the critical period of counselor development, GCF also must be considered within the context of counselor education. GCF during the formative period of graduate-level education in counseling can impede overall skill development. As new counselors find themselves more likely to experience compassion fatigue (Figley, 1995), the same may hold true for GCF. GCF may result in a type of developmental stalling in which counseling students feel an “empathy overload.” Such an overload of empathic emotions may impede the student’s transformation into a counselor. This provides implications for counselor education programs to measure students’ responses to emotionally distressing stimuli (O’Brien & Haaga, 2015) of both clinical and global nature as well as openly and unashamedly discuss signs and symptoms of impairment (Merriman, 2015).
I propose that counselors can manage GCF similarly to compassion fatigue because of the possibility of the two phenomena appearing symptomatically similar. However, GCF requires a greater level of self-awareness, recognition, and acceptance in order to address it. Counselors must learn how to distinguish between the two concepts and understand the possibility for overlap. A number of tools used to manage compassion fatigue can be used for GCF. Supervision, personal counseling, and consultation are all avenues of accountability, monitoring, and fidelity to the profession (Bernard & Goodyear, 2014). Although advocacy can be another tangible method of preventing or mitigating GCF, activism can cause emotional, mental, and physical exhaustion (Chen & Gorski, 2015); therefore, advocacy paired with careful attention to wellness can allow counselors to be most effective in helping to address global issues (Roysircar, 2009). Self-care practices and a wellness lifestyle may also act as protective factors to GCF. Myers et al. (2000) noted, “If one’s spirituality is healthy . . . [it] provides a firm foundation and core for the rest of the components of wellness” (p. 258). This indicates counselors developing an optimistic outlook in response to global events creates greater buffering or management of GCF. Similarly, these authors also state that self-direction allows a person to “move smoothly through time and space”
(p. 258). The cumulative pressure of global stressors necessitates firm self-direction to maintain focus in the chaos of present time and space. Wellness is cumulative and enhances longevity for professional practice (Myers et al., 2000). Ultimately, counselors are ethically responsible for ensuring they practice healthy boundaries and work within their competencies (ACA, 2014). An open dialogue with colleagues, self-awareness of strong responses to global events, pursuing systemic change through advocacy, and cultivating personal wellness encourage management of GCF (Robino & Pignato, 2017).
GCF holds particular relevance for counselors of color. Individuals from historically marginalized populations must understand, identify, and address their experiences and the effects of systemic and individualized racism as well as the psychological trauma of oppression and marginalization (Carter, 2007). The number of publicized events that occur in relation to civil rights issues and social justice concerns warrant additional consideration of GCF in specific populations. For example, police brutality against Black males can cause GCF in many counselors, particularly in counselors of color because of the negative psychological health outcomes for communities of color that stem from racism and discrimination (Carter & Forsyth, 2009; Comas-Díaz, 2016). Furthermore, violence (e.g., the Charleston, South Carolina, shooting targeting a specific religious group consisting of people of color and the Charlottesville, Virginia, protests that resulted in the death of a counter-protester) and localized natural disasters (e.g., fires in Tennessee and the Western United States that affected entire communities and hurricanes like Harvey, Irma, and Maria that caused devastation in the Southern United States and Puerto Rico) also increase the risk of GCF in counselors indirectly or somewhat directly exposed to these events. At the time of this writing, the president of the United States has signed an Immigration Executive Order (Executive Order No. 13,769, 2017) that calls for banning residents of certain Middle Eastern countries from entering the United States. In addition, the public expressed outrage at the removal of children from families seeking asylum at the U.S.–Mexico border (Goldstein, 2018). Such traumatic events become a systemic, multi-level public health issue (Magruder, McLaughlin, & Elmore Borbon, 2017) and increase the possibility of GCF among concerned individuals, including counselors and counseling students.
The emergence of this concept paves the way for a broad range of research avenues. First, I recommend the study of GCF in counselor education programs. With CITs particularly sensitive to the nuances of the counseling profession (Bernard & Goodyear, 2014), the critical period of graduate education requires an examination into how GCF can affect counselor development. Second, the management of GCF calls for greater practice of self-care and exercising of insight. For example, researchers could explore the use of mindfulness and reflexivity in assessing how to treat counselors impacted by global events. Additionally, future research could explore the relationship of counselors’ social media use and GCF experiences. Statistics indicating the increase of social media as a news source (Gottfried & Shearer, 2016) raise questions of how counselors are impacted by their own internet activity. Researchers also could investigate counselor advocacy on social media. Although this article proposes that counselors may experience frustrations that contribute to GCF as a result of social media exposure to distressing global events, Dr. Holcomb-McCoy described social media as a tool for advocacy (Meyers, 2017), which may help in mitigating GCF. Such studies may assist counselors in delineating between GCF and other phenomena of impairment.
Finally, greater research is needed to assess and measure GCF. No accurate measurement yet exists for the phenomenon of GCF. Compassion fatigue measurements assess the negative aspects of helping others through direct contact (Figley, 1996). For GCF, this does not address the negative aspects of compassion for indirect exposure to global events. The Impact of Events Scale-Revised (IES-R; Weiss, 2007) measures the subjective distress associated with a traumatic event. However, the IES-R measures symptoms associated with post-traumatic stress disorder. Although it captures the experience of an external global event, it does not capture the transient, yet profound, emotional experience of GCF. The answer to assessing GCF may lie in the development of an instrument that combines compassion fatigue assessments and the IES-R to measure GCF symptoms as it relates to global events.
This article introduces the concept of GCF into the counseling literature. By expanding the literature on other explanations of impairment, we broaden opportunities for self-awareness and professional development. Previously researched impairment concepts require an expansion into this new perspective by incorporating the effects of exposure to current events. This new phenomenon also contributes to counselor wellness research and the importance of maintaining a healthy wellness lifestyle as a deterrent to GCF. Adopting this concept and language into the literature on impairment and wellness encourages further consideration of counselor health, counselors’ management of distressing global events, and how this may impact both counselors and clients as humans.
As counselors become competent in their roles as advocates for social justice, their involvement in critical global events necessitates attention to the cumulative toll such a role may entail. In addition, consistent exposure to emotionally debilitating global events through social media places counselors in a peculiar position in which they must balance their need to remain informed of events and their need to remain healthy and well. Counselors carry the extra responsibility of remaining present and empathic with their clients while also protecting the empathy they experience for the world around them. Counselors’ marginalized and impacted cultural identities also factor into their experiences of GCF. In this regard, wellness becomes not simply an ethical duty, but also a professional imperative in the interest of both counselor and client welfare.
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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Matthew C. Fullen, Jonathan D. Wiley, Amy A. Morgan
This interpretative phenomenological analysis explored licensed professional counselors’ experiences of turning away Medicare beneficiaries because of the current Medicare mental health policy. Researchers used semi-structured interviews to explore the client-level barriers created by federal legislation that determines professional counselors as Medicare-ineligible providers. An in-depth presentation of one superordinate theme, ineffectual policy, along with the emergent themes confounding regulations, programmatic inconsistencies, and impediment to care, illustrates the proximal barriers Medicare beneficiaries experience when actively seeking out licensed professional counselors for mental health care. Licensed professional counselors’ experiences indicate that current Medicare provider regulations interfere with mental health care accessibility and availability for Medicare-insured populations. Implications for advocacy are discussed.
Keywords: Medicare, interpretative phenomenological analysis, mental health, advocacy, federal legislation
Medicare is the primary source of health insurance for 60 million Americans, including adults 65 years and over and younger individuals with a long-term disability; the number of beneficiaries is expected to surpass 80 million by 2030 (Kaiser Family Foundation, 2019; Medicare Payment Advisory Commission, 2015). According to the Center for Medicare Advocacy (2013), approximately 26% of all Medicare beneficiaries experience some form of mental health disorder, including depression and anxiety, mild and major neurocognitive disorder, and serious mental illness such as bipolar disorder and schizophrenia. Among older adults specifically, nearly one in five meets the criteria for a mental health or substance use condition, and if left unaddressed, these issues may lead to consequences such as impaired physical health, hospitalization, and even suicide (Institute of Medicine, 2012).
Past research demonstrates that Medicare-eligible populations respond appropriately to counseling (Roseborough, Luptak, McLeod, & Bradshaw, 2012). Federal agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA) publish entire guides on how to use counseling to treat depression and related conditions in older adults (SAMHSA, 2011). However, researchers have noted specific challenges that Medicare-eligible populations, such as older adults, face when trying to access mental health services. Stewart, Jameson, and Curtin (2015) described acceptability, accessibility, and availability as three intersecting dimensions that may influence whether an older adult in need of help is able to access care. In contrast to acceptability, which focuses on whether older individuals are willing to participate in specific mental health services, accessibility and availability are both supply-side issues that impede older adults’ engagement with mental health services. Accessibility refers to factors like funding for mental health services and providing transportation support to attend appointments. Availability is used to describe the number of mental health professionals who provide services to older adults within a particular community.
Stewart et al.’s (2015) framework is useful when examining current Medicare policy and its impact on beneficiaries’ ability to participate in mental health treatment when needed. Experts have criticized Medicare for its relative inattention to mental health care (Bartels & Naslund, 2013), noting a remarkably low percentage of its total budget is spent on mental health (1% or $2.4 billion; Institute of Medicine, 2012), as well as a lack of emphasis on prevention services. In terms of accessibility, Congress has made efforts to remove restrictions to using one’s health insurance to access mental health treatment. For example, mental health parity laws were passed in 2008 to ensure that Medicare coverage for mental illness is not more restrictive than coverage for physical health concerns (Medicare Improvements for Patients and Providers Act of 2008, 2008). Yet current Medicare policy may restrict the availability of services at the mental health provider level. For example, the Medicare program has not updated its mental health provider licensure standards since 1989, when licensed clinical social workers were added as independent mental health providers and restrictions on services provided by psychologists were removed (H.R. Rep. No. 101-386, 1989). Although counseling is only one mental health care modality available to Medicare beneficiaries, counselors can play a prominent role in the mental health treatment of older adults and people with long-term disabilities.
Meanwhile, there are references in the literature to a provider gap that may influence the ability of Medicare beneficiaries, including older adults, to access mental health services. A 2012 Institute of Medicine report described the lack of mental health providers as a crisis, and experts on geriatric mental health care have decried the lack of mental health professionals who focus their work on older adults (Bartels & Naslund, 2013). Despite these concerns, relatively little attention has been given to the influence of Medicare provider regulations in limiting the number of available providers. Scholars have noted that a significant proportion of graduate-level mental health professionals are currently excluded from Medicare regulations, despite providing a substantial ratio of community-based mental health services (Christenson & Crane, 2004; Field, 2017; Fullen, 2016; Goodman, Morgan, Hodgson, & Caldwell, 2018). Licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) jointly comprise approximately 200,000 providers (Medicare Mental Health Workforce Coalition, 2019), which means that approximately half of all master’s-level providers are not available to provide services under Medicare. Since their recognition as independent mental health providers by Congress in 1989, only licensed clinical social workers and advanced practice psychiatric nurses have constituted the proportion of master’s-level providers eligible to provide mental health services through Medicare.
Despite current Medicare reimbursement restrictions, Medicare beneficiaries are likely to seek out services from LPCs. Fullen, Lawson, and Sharma (in press-a) found that over 50% of practicing counselors had turned away Medicare-insured individuals who sought counseling services, 40% had used pro bono or sliding scale approaches to provide services, and 39% were forced to refer existing clients once those clients became Medicare-eligible. When this occurs, the Medicare mental health coverage gap (MMHCG) impacts providers and beneficiaries in several distinct ways. First, some beneficiaries may begin treatment only to have services interrupted or stopped altogether once the provider is no longer able to be reimbursed by Medicare. This can occur because of confusion about whether a particular patient’s insurance coverage authorizes treatment by a particular provider type, or when beneficiaries who have successfully used one type of coverage to pay for services transition to Medicare coverage because of advancing age or qualifying for long-term disability.
Most Medicare beneficiaries (81%; Kaiser Family Foundation, 2019) have supplemental insurance, including 22% who have both Medicare and Medicaid. Medicare beneficiaries who are dually eligible for Medicaid may be particularly vulnerable to the MMHCG. In most states, Medicaid authorizes LPCs to provide counseling services; however, in certain cases when these individuals also qualify for Medicare, the inconsistency in provider regulations between these programs can interfere with client care. A similar problem occurs when the Medicare-insured attempt to use supplemental plans (e.g., private insurance, Medigap) because of Medicare functioning as a primary source of insurance, and supplemental plans requiring documentation that a Medicare claim has been denied. Regardless of the reason for having to terminate treatment prematurely, early withdrawal from mental health treatment has been described as inefficient and harmful to both clients and mental health providers (Barrett et al., 2008).
The MMHCG also can interfere with clients’ ability to access services because of a lack of Medicare-eligible providers in a particular geographical region. For example, beneficiaries who reside in rural localities can have more difficulty finding mental health providers because of a general shortage of providers in these areas (Larson, Patterson, Garberson, & Andrilla, 2016). Larson et al. (2016) found that rural communities were less likely to have licensed mental health professionals overall, although these localities were more likely to have a counseling professional than a clinical social worker, psychiatric nurse practitioner, or psychiatrist. Historically, older adults from rural and urban localities experience a comparable prevalence of mental health disorders (Center for Behavioral Health Statistics and Quality, 2018). However, studies consistently describe low rates of mental health services accessibility and availability within rural communities (Smalley & Warren, 2012). Establishing counselors as Medicare-eligible providers can reduce the disparities of mental health services accessibility and availability experienced by older adults in rural communities.
Although it is known that LPCs are currently excluded from Medicare coverage, it is not well understood what sort of impact this has on mental health providers and the Medicare beneficiaries who seek their services. Recent efforts to raise awareness of this issue have emerged in the literature (Field, 2017; Fullen, 2016; Goodman et al., 2018), but there has not yet been an investigation into the phenomenological experiences of mental health providers who are directly impacted by existing Medicare policy. The purpose of this study was to explore the lived experiences of mental health professionals who have turned away clients because of their status as Medicare-ineligible providers. The primary research question for this study was: How do Medicare-ineligible providers make sense of their experiences turning away Medicare beneficiaries and their inability to serve these clients?
Research Design and Methods
This study was executed using interpretive phenomenological analysis (IPA) to guide both data collection and analysis. The study focused on the experiences of Medicare-ineligible mental health professionals as they navigated interactions with Medicare beneficiaries who sought mental health care from them. By using a hermeneutic approach to understand their unique perspectives on this phenomenon, we aimed to remain consistent with the philosophical approach of IPA, which is idiographic in nature (Smith, Flowers, & Larkin, 2009). This study received approval from the Western Institutional Review Board.
IPA focuses on the personal meaning-making of participants who share a particular experience within a specific context (Smith et al., 2009). We determined IPA to be the most appropriate method to answer our research question because of the personal impact on LPCs of turning away Medicare beneficiaries because of Medicare-ineligible provider status. Nationally, LPCs share the experience of being unable to serve Medicare beneficiaries because of the current Medicare mental health policy that establishes these licensed mental health professionals as Medicare-ineligible. IPA also is appropriate for this study because of the positionality of the researchers. The research team consisted of two LPCs and one LMFT who have denied services or had to refer clients because of the current Medicare mental health policy and have engaged in prior research and advocacy related to the professional and clinical implications of the current Medicare mental health policy. We selected IPA for this study because of the shared experience between the researchers and participants as Medicare-ineligible providers. A distinguishing feature of IPA, a variation of hermeneutic phenomenology, is the acknowledgment of a double-interpretative, analytical process: The researchers make sense of how the participants make sense of a shared phenomenon (Smith et al., 2009).
Participants were screened based on the inclusion criteria of having direct experience with turning away or referring Medicare beneficiaries and holding a mental health license as an LPC. Because states grant licenses to health care providers, we limited participation to LPCs who were practicing in a specific state in the Mid-Atlantic region. This allowed for consistency in licensure requirements, training provided, and current scope of practice across all participants. The nine participants interviewed all held the highest professional counseling license in this state, which allows these individuals to practice independent of supervision after completing 4,000 hours of supervised training. Post-license experience ranged from 6 months to 17 years, and participants practiced in both rural and non-rural settings. Pseudonyms were assigned by the research team (see Table 1 for participant information).
||Years of Licensed Experience
|| 4 years
|| 5 years
|| 2 years
|| 4 years
|| 4 years
|| 0.5 years
|| 5 years
aThe table displays rural status as designated by the U.S. Department of Health and Human Services Health Resources and Services Administration (2016) according to the practice location of the participant. Non-rural includes metropolitan and micropolitan areas. Rural indicates any locality that is neither metropolitan or micropolitan.
Most participants were identified because of having completed a national survey of mental health providers unable to serve Medicare beneficiaries (Fullen et al., in press-a). Participants in the national survey were provided with a question in which they were able to indicate their openness to participating in follow-up individual interviews regarding their experiences with turning away clients as a result of Medicare policy. Two additional participants had not completed the national survey but were identified locally because of their unique experiences with the phenomenon under investigation. We selected nine participants in accordance with IPA participant selection and data saturation guidelines (Smith et al., 2009). Although the current Medicare policy excludes both LPCs and LMFTs, we chose to focus on the experiences of LPCs to ensure a purposive and homogeneous sample (Smith et al., 2009).
Semi-structured, in-depth interviews of the nine participants were conducted by the research team. All research team members are LPCs or LMFTs. Individual interviews were conducted by a single member of the team who digitally recorded and transcribed verbatim the interview procedure. Consent was obtained from the participants and pseudonyms were used to ensure participant confidentiality. Also, participants were given the option to stop the interview at any time. The elapsed time of each interview ranged between 47 and 66 minutes. The semi-structured interview protocol began with two initial questions to frame the interview: (a) Have you ever had to refer a potential client to another counselor/therapist/agency because of not being able to accept their Medicare insurance coverage? and (b) Have you ever established a working relationship with a client who later transitioned to Medicare insurance coverage?
Based on participant responses to these initial questions, two grand tour questions followed:
(a) Tell me about what typically occurs when someone with Medicare insurance contacts your office in search of counseling? and (b) Tell me about any times when you have had to alter a pre-existing working relationship with a client because of their Medicare coverage? Follow-up questions focused on the impact of current Medicare mental health policy on the interviewees, as well as their perceived impact on clients, local communities, other therapists in the area, and their employment contexts.
The IPA process outlined by Smith et al. (2009) was employed to analyze the transcribed interview data. The following steps were employed throughout the analysis process: (a) reading and re-reading of transcripts, (b) initial noting, (c) developing emergent themes, (d) searching for connections across emergent themes, (e) moving to the next case, and (f) looking for patterns across cases. Codes and themes developed at each stage of the first transcript analysis required consensus agreement among the authors. After re-reading, initial noting, developing emergent themes, and clustering of superordinate themes for each of the remaining interviews, the authors proceeded to engage in a group-level analysis process of looking for patterns across all interviews. Patterns across all interviews were organized into a concept map to synthesize connections and relationships between the interviews. Connections and relationships identified through this cross-case analysis led to the identification of a group-level clustering of superordinate themes that resulted in the identification of the primary themes.
The authors attended to the credibility and trustworthiness of this analysis using four strategies. First, the authors have prolonged engagement in the fields of counseling and marriage and family therapy as licensed professionals. This prolonged engagement has allowed the authors to be situated to the contexts of the participants, account for abnormalities in the data, and transcend their own observations (Lincoln & Guba, 1985). Second, the authors engaged in a team-based reflexive process through the sharing of personal reflections and group discussions about emerging issues (Barry, Britten, Barber, Bradley, & Stevenson, 1999). Third, negative case analysis was used in the analytical process of this study to develop, broaden, and confirm themes that emerged from the data (Lincoln & Guba, 1985; Patton, 1999). The fourth strategy was analyst triangulation (Denzin, 1978; Patton, 1999). All three authors participated in the development of the study, data collection, and data analysis to reduce the potential bias that can emerge from a single researcher performing each of these tasks (Patton, 1999). Each researcher independently analyzed the same data and compared their findings throughout data analysis to check selective perception and interpretive bias.
Three superordinate themes emerged from our interviews with nine mental health professionals who have experience with the Medicare coverage gap: ineffectual policy, difficult transitions, and undue burden. We will discuss one superordinate theme, ineffectual policy, with the emergent themes of confounding regulations, programmatic inconsistencies, and impediment to care. By presenting a single meta-theme, we hope to provide increased depth and the nuanced experiences that our participants shared (see Levitt et al., 2018 for a discussion on dividing qualitative data into multiple manuscripts).
All nine participants expressed concerns about the ineffectiveness of current Medicare policy when it comes to treating people with mental disorders who live in their communities. The disconnect between Medicare’s intended aim—to provide sound health care to beneficiaries—and the present outcome for clients seeking out counseling led us to describe the policy as ineffectual or not producing the intended effect. Our participants perceived that the policy had severe shortcomings in terms of providing access to mental health care, which they viewed as a serious problem with cascading consequences for their clients, communities, and themselves.
Several participants described the Medicare coverage gap as “confusing” and “frustrating” for mental health providers and Medicare beneficiaries who are seeking mental health services. Brandon, an LPC who serves as a director within a Federally Qualified Health Center, stated, “Most people are pretty shocked to realize we are not part of Medicare.” He went on to explain that most medical providers, including psychiatrists, were not aware of LPCs’ Medicare ineligibility when making client referrals. Participants described how the confusion interferes with referrals between medical providers and clients seeking mental health services.
Other participants described how frustrating the policy is, both for themselves and their clients. Robert, an LPC who also is credentialed as an LMFT, stated that “as a provider, it’s frustrating to turn people away,” and “it’s especially concerning for older people who can’t afford to pay out of pocket.” Michelle, who works as an LPC in a rural community, described how the MMHCG influences clients’ views of the larger Medicare system, stating, “[Clients are] very angry—not directed towards me, just the system . . . they’re on Medicare now [and] they have to leave. They paid into a system and then still can’t see the clinician that they want to see.” According to interviewees like Michelle, current Medicare provider regulations do not account for the preponderance of LPCs who provide care, particularly in rural communities. Regulations are then perceived by clients as an additional barrier to getting help at a time when they may be vulnerable.
In fact, in certain cases, current Medicare policy may result in all Medicare beneficiaries within a particular community losing access to mental health care. Brandon described a 4-month period when his Federally Qualified Health Center was unable to serve any Medicare beneficiaries because of job turnover: “[It] took us four months to find an LCSW. . . . We specifically had to weed out some very qualified licensed mental health professionals because they weren’t LCSWs.” Brandon went on to explain that during this 4-month period, his clients were unable to access mental health care at the community clinic. He concluded, “It was pretty disruptive to their care.”
Brandon’s description elucidates the cascading impact of the current policy on clients, community agencies that provide mental health services, and counselors seeking work. When specific providers are excluded from servicing Medicare beneficiaries, older adults with mental health conditions are vulnerable to gaps in coverage, such as the 4-month period that Brandon described.
Several interviewees referenced confusion about how Medicare interfaces with other insurance programs. Roger and Mary, a couple in joint practice, explained how confusion among clients and health providers in their community is exacerbated by inconsistencies between Medicare and Medicaid, including the fact that in their state LPCs are eligible for reimbursement from Medicaid, but not Medicare. Roger explained, “[The] confusion is not just with clients who have low SES. It’s agency people, it’s case managers in the community, doctors that would make referrals, there really is a misunderstanding . . . and sometimes a disbelief.” They went on to describe their frustration in having to explain to referral sources that Medicare ineligibility has nothing to do with a lack of training. Roger concluded, “Yes, we are trained and . . . virtually every other insurance company accepts licensed professional counselors.”
Mary’s and Roger’s statements are indicative of the confusion that current policy creates among providers and clients. Several interviewees expressed annoyance that they had to explain to prospective clients that they possessed the requisite license and training required by the state to provide counseling and that they were recognized providers by non-Medicare insurance providers (i.e., Medicaid, Tricare, private insurance providers).
Related to the inconsistency between Medicaid and Medicare, several interviewees alluded to the fact that the very circumstances that qualify individuals for government-funded insurance (e.g., poverty, disability) may inadvertently restrict the mental health care that is available to them. Michelle described this phenomenon in the context of having to address clients who were referred to work with her by the local community mental health agency. She alluded to a particularly challenging cycle in which clients who were diagnosed with schizophrenia would be referred to her for counseling while they were also applying for long-term medical disability. She described the challenges of working with these clients, only to have to refer them elsewhere once they became eligible for disability benefits (which include Medicare). Describing her clients, she stated, “[They] applied for disability, they received disability, and now they have to, even though they have established the relationship with me . . . transition over to a different therapist.” Michelle then highlighted what occurs after this transition is initiated: “[One] individual . . . has continued to see me because with that particular diagnosis, he doesn’t trust anyone else. . . . [Another] individual . . . just chooses not to see anyone . . . and then she ends up having to be hospitalized every so often.”
Beyond being discouraged or exasperated, Michelle’s capacity to remain stoic in the face of such a paradox was telling. As she described it, this sequence had happened on multiple occasions and would likely happen again save for a federal policy change. Michelle also alluded to the potential economic detriments of current policy. By foregoing outpatient counseling because of the barriers described above, her patient with schizophrenia must be intermittently hospitalized, which is a much more expensive form of treatment.
Policy-level inconsistencies were confusing to providers as well. April, an LPC who attained her independent license within the past year, stated, “It feels like handcuffs. It’s like here you have this credential that the state says you have earned, but it’s only a half credential because you can’t [accept] one of the main government sponsored programs.” Cecelia, an LPC working in a metropolitan area, expressed similar sentiments as she explained how clients with Medicare and secondary insurance plans are turned away: “I initially bill Anthem first and my claims continue to get denied.” She explained, “Basically what they want me to do is submit the claims to Medicare, allow Medicare to deny the claim, and then submit the claim to them with the denial from Medicare and then they’ll provide reimbursement.” However, Cecelia stated that this process has been halted when Medicare refuses to issue a denial letter because of her status as an LPC. She put it this way: “The struggle that I found with Medicare is that because I’m an LPC, Medicare won’t even recognize me to even allow me to submit a claim . . . so I cannot provide Anthem with the denial that they’re looking for.”
Cecelia’s description of the inconsistency between Medicare and private insurance reflects a particularly problematic experience for her clients. Although they had paid for supplemental private insurance plans to augment their Medicare coverage, they were unable to use these benefits without a denial letter from Medicare. Ironically, according to Cecelia, the Medicare office could not provide the denial to a Medicare-ineligible provider in the first place.
Brandon made a similar statement about the inconsistency in provider regulations between Medicare and Tricare, specifically referencing his own training levels: “I’m shocked. . . . We’re some of the most qualified licensed mental health professionals in the business to provide psychotherapy and treatment for psychiatric diagnoses . . . and yet somehow that doesn’t count . . . somehow we’re not included.” Citing the growing number of insurance providers that do recognize LPCs, including Tricare, he concluded, “So, literally Medicare is the last holdout that I’m aware of.” By describing Medicare as “the last holdout,” Brandon implies that Medicare is the only federal program that has not updated its provider regulations to match the current mental health marketplace. Echoing Brandon, the sentiment that Medicare provider regulations were not in line with the current state of mental health practice was common among our interviewees.
Impediment to Care
The therapeutic working alliance has been shown to be one of the key factors that positively impacts counseling treatment (Wampold, 2015). When existing clients become eligible for Medicare, whether because of increasing age or qualifying for a long-term disability, current policy appears to interfere with continuity of care. Aubrey, an LPC who practices in a rural locality, describes it this way: “I will tell you where the problem arises . . . if I’m assigned a client, and I have the rapport with them, and we’re working together and they become eligible for Medicare . . . then I have to transfer them.” Because of the emphasis within counseling on the working relationship, Aubrey suggested that after building a strong working relationship with a counselor, even referrals within an agency can be disruptive to patient care.
Additionally, several interviewees described the challenges associated with referring Medicare beneficiaries to alternative providers. Some alluded to clients who made an effort to continue working with an LPC, despite not being able to use their Medicare coverage. Eventually, disparities in clients’ financial circumstances resulted in some clients having to forego receiving mental health care. Brandon explained the difficulty that current Medicare policy brings to communities, particularly those in which there are relatively few Medicare-eligible providers relative to LPCs. He described monthly meetings with community private practice providers this way: “[They are] all booked up. There’s just not enough . . . licensed mental health providers in town to see everybody. And . . . because only half of those people can accept Medicare, it has a very particular impact on Medicare recipients.” Citing the shortage of providers, Brandon emphasized the additional burden faced by the Medicare-insured because of having a smaller available provider pool.
The shortage of alternative mental health providers was a common theme among interviewees, especially for those who practiced in rural communities. Michelle explained that there is a misperception that Medicare-eligible providers are available when Medicare beneficiaries seek out help: “I hear . . .
there are so many licensed clinical social workers in this area, but there aren’t.” As a consequence, “[individuals] that are trying to work themselves into the schedule of a licensed clinical social worker, they often wait months before they’re actually able to be seen.”
Donna, an LPC who also works in a rural community, expressed a similar concern about the lack
of options facing beneficiaries who live in rural areas: “I see such a shortage in rural areas of providers across the board. And then when you have to narrow it down even further to limit who they can see, then that makes it even more difficult for them to get the care that they need.”
In fact, the expense of mental health care when insurance coverage is unavailable was a factor that several interviewees described. Robert told the story of a client he had seen for several years who tried to pay out of pocket but could no longer make that financially viable: “[It] was really disappointing because she really wasn’t finished. . . . We had a great working relationship and it was sad to have her stop just because of reimbursement reasons.”
Brandon made a similar comment about an individual who was deterred from seeking treatment because of the cost of paying out of pocket when his Medicare insurance was unable to be used: “I let him know . . . I can’t accept Medicare. And he asked how much it would be. [I said] anywhere from $75 to $125, and . . . he was pretty disheartened by that.”
Mary noted how the MMHCG can result in Medicare beneficiaries not seeking out necessary services. She emphasized that turning people away at the point when they have elected to ask for help can be disconcerting: “Right at a time when they’re willing to reach out and ask for [help]. That’s the worst part. Because I think . . . that discourages clients from seeking services—they have to work too hard . . . finding a provider.” April added a similar sentiment: “It’s heartbreaking . . . [my] emphasis is on those most vulnerable and those most in need of services . . . it is my worst nightmare for a client to walk away . . . because I want them to know they are my priority.” In each of these examples, participants expressed concerns that current policy acted as a deterrent to accessing necessary mental health services because of the burdensome process of having to locate a Medicare-eligible provider.
Our findings illuminate how current Medicare mental health policy impacts Medicare beneficiaries’ access to counseling treatment for mental health conditions. Nine mental health providers who are not Medicare-eligible were interviewed to learn about their experiences interacting with Medicare beneficiaries who sought their services. The central phenomenon that all interviewees responded to—their inability to work with Medicare beneficiaries in the same manner that they work with clients who use other forms of insurance—has infrequently been referenced in the extant literature. This phenomenon provides a unique contribution to discussions about the accessibility and availability of mental health services to older adults (Stewart et al., 2015) and people with long-term disabilities. Particularly compelling about what was reported in these interviews is the fact that these individuals were actively seeking out or currently engaged in mental health treatment at the time when they were turned away. In the past, explanations about barriers to mental health care for Medicare-insured populations have focused on systemic factors such as rural geography (Kim et al., 2013) or stigma about mental health (Chapin et al., 2013). While these are certainly relevant factors that provide a broad explanation for why older people are less likely to receive mental health services, the current study illuminates several proximate point-of-service barriers that result in providers having to cease treatment with clients, deny care to clients who were actively seeking it out, or refer clients to relatively long wait-lists in lieu of more prompt treatment by available providers. Given the lack of scholarly attention focused on the MMHCG, the perspectives offered by these participants contributes to a broader discussion about how to increase access to mental health services for older adults, as well as for individuals with long-term disabilities.
Among our interviewees, there was a noticeable amount of concern for how the MMHCG impacts individuals in the community in need of mental health care. Participants’ concerns about the consequences of the MMHCG on their clients may be related to their awareness that mental illness influences other key indicators of well-being. For example, depression reflects a relatively common mental health condition that responds well to treatment but can be problematic for clients when left untreated. Although depression was only one of several types of mental illness described by participants, clinically relevant depressive symptoms affect 10% of males over 65 and 15% of females over 65, and the presence of depressive symptoms is correlated with greater functional disability, dementia, higher rates of physical illness, and higher health care resource utilization (Federal Interagency Forum on Aging-Related Statistics, 2016). As the number of Medicare beneficiaries grows, it is reasonable to assume that there will be corresponding growth in the number of people who meet the criteria for mental health conditions, including depression. Echoing the concern voiced by our participants, we state that the current Medicare policy extends the risk of mental health needs going unmet among Medicare-insured populations.
Additionally, the economic consequences of untreated or undertreated mental illness are worth considering. Each participant described instances of unmet client mental health needs because of a combination of (a) practitioner inability to submit for Medicare reimbursement, (b) client’s inability to pay a sliding scale rate, and (c) lack of follow-through on referrals to mental health providers eligible for Medicare coverage. For example, some participants described this undertreatment as resulting in potential inpatient psychiatric hospitalization because of clients’ inability to utilize their Medicare benefits to seek care within their local communities. Undertreatment of mental health conditions can lead to inefficient administration of health care, including an over-reliance on more expensive mental health services when outpatient services could have been more appropriate. For example, the reimbursement rate for 45 minutes of counseling is $84.74 for doctoral-level providers (see American Psychological Association, 2015, for a critique of this rate), and the rate for master’s-level providers is estimated at 75% of this amount ($63.56). This is in contrast to the cost of a single day in an inpatient psychiatric facility, which is $782.78, or approximately 12 times higher than a single counseling session (Centers for Medicare & Medicaid Services, 2019). Having adequate outpatient services available within a community is traditionally a sound strategy for reducing high-cost treatment; yet this is not occurring as regularly as is needed when Medicare beneficiaries are involved. Although not every person who may be at risk for inpatient hospitalization will benefit solely from weekly outpatient services, several cases referenced by our interviewees (e.g., Michelle’s work with clients with schizophrenia) fit this category. Considering that a single day of inpatient treatment costs the same as a 12-session course of counseling from a master’s-level provider, it stands to reason that there are economic benefits to re-examining current Medicare mental health policy.
The inefficiency of current Medicare policy was highlighted when several participants alluded to inconsistencies between insurance programs, including certain cases in which having Medicare precluded clients from using other forms of insurance (e.g., Medicaid, Tricare, private supplemental plans) that would otherwise cover mental health treatment by LPCs. This feature of the MMHCG has important ramifications given that 81% of Medicare beneficiaries possess a supplemental health plan (Kaiser Family Foundation, 2019), including more than 12 million Americans who are dually covered by Medicare and Medicaid (Centers for Medicare & Medicaid Services, n.d.). For this latter group, dual-eligible adults are more likely to have functional or cognitive impairments, chronic conditions, or conditions that frequently coincide with mental health conditions. In fact, among dual-eligible individuals, 59% of those with disabilities and 20% of those who are 65 years or older self-reported diagnosis of a mental health disorder (Donohue, 2006). This means that some of the most vulnerable Medicare beneficiaries are particularly burdened by current Medicare mental health policy.
Implications for Professional Advocacy
Regarding advocacy on behalf of clients, these findings suggest that Medicare reimbursement for LPCs is urgently needed in order to provide Medicare-insured populations with access to mental health services. Currently, efforts to change Medicare regulations through the legislative process have support from a broad range of professional interest groups, many of which comprise the Medicare Mental Health Workforce Coalition (Medicare Mental Health Workforce Coalition, 2019). Further, there is currently legislation under consideration in both the U.S. Senate (S. 286; Mental Health Access Improvement Act, 2019) and U.S. House of Representatives (H.R. 945; Mental Health Access Improvement Act, 2019) that would include LPCs and LMFTs as Medicare-eligible providers. As of November 2019, these bills had 29 and 96 cosponsors, respectively (U.S. Congress 2019a, 2019b). Despite these efforts, more than half of counseling professionals recently surveyed had not participated in advocacy related to Medicare reimbursement (Fullen, Lawson, & Sharma, in press-b). Therefore, additional work is needed to educate members of the counseling profession about the consequences of current Medicare mental health policy on clients from underserved populations. Fullen et al. (in press-a, in press-b) describe several strategies that can be used to strengthen advocacy efforts among members of the counseling profession, including counselor educators, master’s and doctoral students, and practicing counselors.
Limitations and Future Research
A primary limitation of this study relates to the generalizability of the results. This study reports on a specific and localized account of how Medicare mental health policy impacts Medicare beneficiaries’ access to counseling treatment in a single state. We intentionally focused on a homogenous sample purposefully selected to explore how LPCs are making sense of their inability to provide counseling services to Medicare beneficiaries based on their professional status as Medicare-ineligible. The findings present a narrative account of how these licensed mental health providers make sense of and respond to the experience of not being able to serve Medicare clients because of professional limitations contained within Medicare mental health policy. The utilization of IPA has allowed for the detection of nuance, subtlety, and complexity within the data from the semi-structured interviews with our participants. This specificity allows for an understanding that shows how the coverage gap created by the exclusion of counselors impacts Medicare beneficiaries’ access to counseling services.
An additional limitation of our study is the use of prolonged engagement as a strategy to establish credibility and trustworthiness. Prolonged engagement, traditionally employed in ethnography and
participant observation, requires that researchers spend sufficient time in the field to learn or understand the experiential phenomenon of the study (Lincoln & Guba, 1985). Though we did not spend time with participants within their specific practice settings, we each have practice experience as Medicare-ineligible providers within the field of professional counseling. In a more ethnographic study on the MMHCG, we would be able to employ a more traditional application of prolonged engagement.
Future research should focus on additional qualitative and quantitative data sets that allow for more generalizability of findings. By nature, Medicare policy is consistent across the United States, which leads us to believe that there are likely similarities between the phenomena described by our interviewees and what occurs in other states. Nonetheless, additional inquiry is needed to probe the impact of MMHCG more comprehensively. An empirical investigation into the perspectives of Medicare-insured individuals who have been unable to utilize their Medicare benefits because of the MMHCG may lend an additional lens toward understanding the impact of Medicare mental health policy on clients. Ultimately, this study and subsequent studies focusing on diminishing coverage gaps for Medicare beneficiaries can support progress toward diminishing health inequities because of health care policy restrictions.
This study highlights an existing gap in the administration of Medicare services for clients seeking counseling treatment for mental health conditions. By attending to the theme of ineffectual policy, we have attempted to illuminate how current policy impacts the Medicare-insured, as well as LPCs who are involved in their mental health care. Based on our analysis of the MMHCG, future revisions to Medicare policy allowing for the inclusion of LPCs to provide counseling treatment to Medicare-insured individuals may contribute to a more equitable health care system for Medicare beneficiaries.
Conflict of Interest and Funding Disclosure
This research was supported by the Virginia Tech
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Matthew C. Fullen is an assistant professor at Virginia Tech. Jonathan D. Wiley, NCC, is a doctoral candidate at Virginia Tech. Amy A. Morgan is a doctoral candidate at Virginia Tech. Correspondence can be addressed to Matthew Fullen, School of Education, College of Liberal Arts and Human Sciences, 1750 Kraft Drive, Suite 2000, Room 2005, Blacksburg, VA 24061, firstname.lastname@example.org.