Integrating Social Justice Advocacy Into Mental Health Counseling in Rural, Impoverished American Communities

Loni Crumb, Natoya Haskins, Shanita Brown


This phenomenological study explored the experiences of 15 professional counselors who work with clients living in impoverished communities in rural America. Researchers used individual semi-structured interviews to gather data and identified four themes that represented the counselors’ experiences using the Multicultural and Social Justice Counseling Competencies as the conceptual framework to identify the incorporation of social justice and advocacy-oriented counseling practices. The themes representing the counselors’ experiences were: (1) appreciating clients’ worldviews and life experiences, (2) counseling relationships influencing service delivery, (3) engaging in individual and systems advocacy, and (4) utilizing professional support. The counselors’ experiences convey the need to alter traditional counseling session delivery formats, practices, and roles to account for clients’ life experiences and contextual factors that influence mental health care in rural, impoverished communities. Approaches that counselors use to engage in social justice advocacy with and on behalf of rural, impoverished clients are discussed.

Keywords: rural, impoverished communities, advocacy, social justice, multicultural


Approximately 41.3 million Americans live in poverty (Semega, Fontenot, & Kollar, 2017) and consistently face multiple chronic stressors (e.g., food and housing insecurities, social isolation, inability to access adequate physical and mental health care) that impact their quality of life (Fifield & Oliver, 2016; Hill, Cantrell, Edwards, & Dalton, 2016). Nevertheless, the scope of mental health concerns of individuals and families residing in persistently poor, rural communities remains under-researched and overlooked by the public, scholars, and policymakers (Tickamyer, Sherman, & Warlick, 2017). Furthermore, advocacy efforts that foster social and economic justice and support the mental health of persons living in rural poverty warrant further advancement.

Scarce availability of mental health care services, ineffective modes of treatment and interventions, and mistrust of mental health care professionals contribute to the low utilization of mental health care services among persons living in rural poverty (Fifield & Oliver, 2016; Imig, 2014). Consequently, there are few evidence-supported culturally relevant mental health interventions tailored to address the specific needs of people living in rural poverty, particularly with a focus on social justice advocacy (Bradley, Werth, Hastings, & Pierce, 2012; Imig, 2014). Counselors practicing in rural, impoverished areas must be prepared to address systems of oppression, discrimination, marginalized statuses, and the impact these factors have on counseling services and clients’ well-being (Grimes, Haskins, & Paisley, 2013; Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016). Moreover, according to the 2016 Code of Ethics from the National Board for Certified Counselors (NBCC) and the 2014 ACA Code of Ethics from the American Counseling Association, counselors are expected to take actions to prevent harm and help eradicate the social structures and processes that reproduce mental health disparities in vulnerable communities (ACA, 2014; NBCC, 2016). In recognition of this expectation, the Multicultural and Social Justice Counseling Competencies (MSJCCs) were developed to guide mental health counselors toward practicing culturally responsive counseling and incorporating social justice advocacy initiatives into the process (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015). Thus, the MSJCCs’ framework undergirds our examination of counselors’ experiences and clinical practices that support the mental health and well-being of clients living in poverty in rural America.


Understanding Rural Poverty and Mental Health Care

When discussing literature pertaining to rural poverty, it is important to first define relevant terms. The U.S. Department of Agriculture’s Economic Research Service (USDA; 2017) defines poverty as having an income below the federally determined poverty threshold. For example, the 2017 poverty threshold for an individual under 65 years of age was $12,752, and the poverty threshold was $16,895 for a household with two adults under age 65, with one child under 18 years of age (USDA, 2017). Persistently poor areas are defined as communities in which 20% or more of the population has lived below the poverty threshold over the last 30 years with low populations (fewer than 2,500 people; USDA, 2017). The majority of persistently poor communities are located in rural Southern regions of the United States (USDA, 2017). Rural communities that experience persistent poverty have had little diversification of employment, are underserved by mental health care providers, and lack affordable housing and economic development (Tickamyer et al., 2017). For the purposes of this study, the definitions described above were used to define and understand rurality and poverty.


Mental Health Care in Rural, Impoverished America

An abundance of literature exists that identifies concerns related to mental health care for people who live in rural poverty (Reed & Smith, 2014; Tickamyer et al., 2017). For example, Snell-Rood and colleagues (2017) conducted a qualitative study that explored the sociocultural factors that influence treatment-seeking behavior among rural, low-income women. Participants reported that the quality of counseling in their rural settings was unsatisfactory because of counselors recommending coping strategies that were “inconsistent” with daily routines and beliefs (Snell-Rood et al., 2017). Alang (2015) conducted a quantitative study that investigated the sociodemographic disparities of unmet health care needs and found that men in rural areas were more likely to forgo mental health treatment because of gender stereotypes. Specifically, Alang found that men were encouraged to ignore mental health concerns and avoid help-seeking behaviors. Furthermore, children living in rural poverty have fewer protective resources and less access to services that can address their needs and are subsequently exposed to increased violence, hunger, and poor health (Curtin, Schweitzer, Tuxbury, & D’Aoust, 2016).

Adults and children living in rural poverty often have lower mental health literacy (i.e., the ability to recognize a mental health concern when it arises and how to cope with one when it occurs; Rural Health Information Hub, 2017). For example, researchers (Pillay, Gibson, Lu, & Fulton, 2018) examined the experiences of the rural Appalachian clients who utilized mental health services and found that clients were ambivalent about diagnoses and suspicious when providers suggested psychotropic medications to support treatment. Likewise, Haynes et al. (2017) conducted focus group interviews that included persons living with a mental illness, health care providers, and clergy living in rural, impoverished communities in the Southern United States, and reported a general lack of awareness about mental illness. The researchers suggested that individuals have less knowledge of what mental illness looks like, how to recognize it, and how to identify warning signs of crises in Southern rural, impoverished communities (Haynes et al., 2017). As a result of less mental health literacy, people in rural low-income communities may delay seeking counseling treatment until symptoms have intensified and face a greater likelihood of hospitalization related to mental health challenges (Neese, Abraham, & Buckwalter, 1999; Stewart, Jameson, & Curtin, 2015).


Counselor Competence and Poverty Beliefs

Researchers have indicated that mental health professionals practicing in rural, economically deprived areas are not properly trained to address the multiple needs of this population (Bradley et al., 2012; Fifield & Oliver, 2016; Grimes, Haskins, Bergin, & Tribble, 2015). Fifield and Oliver (2016) surveyed 107 rural clinicians, exploring their perceived training-related needs and the pros and cons of rural counseling practice. The researchers found that many counselors did not receive adequate training to work with the population they served, and the counselors did not feel properly prepared to address the host of issues that may arise in their rural practice.

Moreover, mental health professionals continue to hold negative poverty beliefs and social class biases (Bray & Schommer-Aikins, 2015; Grimes et al., 2015; Smith, Li, Dykema, Hamlet, & Shellman, 2013) that negatively impact the quality of services provided. Researchers have shown that some counselors are less willing to work with clients of lower socioeconomic statuses because of communication barriers, having less knowledge of and exposure to the poverty culture, and possessing negative stereotypes about poor, rural populations (e.g., uneducated, dirty, violent, lazy; Bray & Schommer-Aikins, 2015; Smith et al., 2013). Consequently, clients from lower socioeconomic statuses receive more serious mental health diagnoses or are often misdiagnosed, which may be attributed to the professional’s negative biases, as well as lack of adequate multicultural training (Clark, Moe, & Hays, 2017).


Multicultural Counseling Competence

Increased training in multicultural counseling competence has a significant impact on counselors’ poverty beliefs (Clark et al., 2017; Toporek & Pope-Davis, 2005). In a quantitative study examining the relationship between multicultural counseling competence and poverty beliefs using a sample of 251 counselors, Clark et al. (2017) identified that higher levels of multicultural competence and training decreased poverty biases and helped counselors to understand the structural causes of poverty. Similarly, Bray and Schommer-Aikins’ (2015) survey of 513 school counselors found that counselors with training through multicultural courses recognized the external factors that contribute to poverty; however, the study did not focus on effective interventions that counselors utilized with this population.

Although these studies identified that multicultural knowledge and awareness increased counselors’ understanding of the culture of poverty, more research is necessary to explore how this information is applied to provide counseling professionals with evidence-based illustrations of social justice advocacy in practice (Ratts & Greenleaf, 2018). Accordingly, the purpose of this study was to (1) develop an understanding of the experiences of mental health counselors who work in rural, persistently poor communities and (2) identify ways that counselors incorporate social justice advocacy into counseling using the lens of the MSJCCs. The research question guiding this study was: What are the lived experiences of mental health counselors working in rural, persistently poor communities?


Conceptual Framework

The MSJCCs, a revision of the Multicultural Counseling Competencies (Sue, Arredondo, & McDavis, 1992), offer a framework to incorporate culturally responsive counseling and social justice advocacy initiatives into counseling practices, research, and curricula (Ratts et al., 2015). Established in a socioecological framework, the MSJCCs help counselors examine personal biases, skills, and the dynamics of marginalized and privileged identities in relation to multiculturalism and social justice counseling competence and advocacy. Additionally, the MSJCCs assist counselors in acknowledging clients’ intersecting identities, which bestow various aspects of power, privilege, and oppression that may impact their growth and development.

The developmental domains of the MSJCCs—(a) counselor self-awareness, (b) client worldview,
(c) counseling relationship, and (d) counseling and advocacy interventions—help counselors understand social inequalities that are perpetuated by institutional oppression in order to better serve historically marginalized clients (Ratts et al., 2015). Likewise, aspirational competencies espoused in the MSJCCs—namely (a) attitudes and beliefs, (b) knowledge, (c) skills, and (d) action—serve as objectives for multicultural, social justice competence and advocacy interventions (Ratts et al., 2015, 2016). Although the MSJCCs have been identified as goals for all counselors, limited research exists that illuminates the MSJCCs as a framework for understanding social justice applications within rural, high-poverty areas. Therefore, in considering the four distinct developmental domains and aspirational competencies, the authors utilized the MSJCCs as a basis to understand counselors’ experiences in rural, high-poverty communities. For the purposes of this study, social justice advocacy is understood as interventions and skills that counselors utilize to address inequitable social, political, or economic conditions that impede the personal and social development of individuals, families, and communities (Lewis, Ratts, Paladino,
& Toporek, 2011).



University institutional review board approval was granted for this study. We used a descriptive phenomenological qualitative research design, which is suitable for scholars to examine the lived experiences of individuals within their sociocultural context (Creswell & Creswell, 2018; Giorgi, 2009). In descriptive phenomenological studies, researchers use participants’ responses to describe common experiences that capture the “intentionality” (perception, thought, memory, imagination, and emotion) related to the phenomenon under study (Giorgi, 2009). Furthermore, using qualitative research methods allows researchers to provide an in-depth exploration of lived experiences and helps multiculturally competent counselor–researchers highlight gaps in counseling literature and inequities in counseling practices in order to advocate for systemic changes in the counseling profession (Hays & Singh, 2012; Ratts et al., 2015).


Role of the Researchers

We recognize the possibility of bias in empirical research and acknowledge our social locations, identities, and professional experiences in relation to the current research study. All three authors identify as African American women from low socioeconomic backgrounds. We identify as counselor–advocate–scholars (Ratts & Greenleaf, 2018) and incorporate advocacy for underserved populations into our counseling practices, research, supervision, and teaching (Ratts et al., 2015). We bracketed personal thoughts and feelings and discussed biases that may possibly influence the data throughout the study. For example, the frequent criminalization of poverty was a difficult finding to discuss with the participants and we met to express our thoughts regarding this finding. A graduate research assistant (middle class, European American female) was selected to assist in data collection and analysis to increase objectivity in the research process, as she was less familiar with underserved populations, but trained extensively in qualitative research techniques. We acknowledge that we used the developmental domains and aspirational competencies espoused in the MSJCCs to conceptualize this research study, analyze the data, and present the findings and implications to foster positive changes in mental health care for people living in rural, poor communities. Furthermore, it is our view that the data did not emerge independently, but that as researchers we used a rigorous process such as the use of thick descriptions to analyze and identify nuances and commonalities in the data while also accounting for our assumptions and biases (Hays & Singh, 2012; Lincoln & Guba, 1986). Our position as counselor–advocate–scholars helps to bring expertise to our scholarship and practices (Hays & Singh, 2012; Ratts & Greenleaf, 2018).



Fifteen participants (N = 15; 13 women, two men) were selected for the study using purposeful criterion sampling (Patton, 2014). Participants’ ages ranged from 28 to 67 years (M = 40). Twelve participants identified as European American and three as African American. Twelve participants were licensed professional counselors and three were licensed professional counselor associates. Two participants had doctoral degrees in counseling. Participants practiced counseling in various settings such as private practices, colleges, secondary schools, and community counseling centers. Participants also had additional credentials: three were licensed professional counselor supervisors, seven were licensed clinical addiction specialists, one was a certified clinical trauma professional, and one was a registered play therapist. Years of work experience as a professional counselor ranged from 2 to 20 (M = 6.7).


Data Collection and Analysis

Recruitment solicitation flyers were distributed to various mental health agencies located in rural counties designated as persistently poor (USDA, 2017) in one state in the Southeastern United States. The mental health agencies were identified by searching public information websites for counseling and psychological support resources within these counties. Potential participants completed a telephone eligibility screening and a demographic questionnaire. The demographic questionnaire included questions asking potential participants to identify a pseudonym, their age, ethnicity, employment status and location, and professional credentials. Participants who met inclusion criteria (i.e., licensed mental health clinicians currently employed in persistently poor rural locales) were selected to participate in the study. There is no required sample size for phenomenological studies; rather, authors (Creswell & Creswell, 2018; Hays & Singh, 2012) recommended researchers consider the purpose of the research and depth of the data. We continued to recruit participants until saturation was achieved by seeing a recurrence in the data (Creswell & Creswell, 2018; Hays & Singh, 2012). After completing Interview 15, we did not identify novel data and agreed that a sufficient amount of data was collected to provide a comprehensive understanding of the phenomenon under investigation.

The researcher is the key instrument for data collection in qualitative research (Creswell & Creswell, 2018). A graduate assistant and the first author collected all study data by the use of qualitative interviews using an open-ended, semi-structured interview protocol (Hays & Singh, 2012). Each participant completed individual, one-phase, open-ended, semi-structured, face-to-face or live video interviews, lasting approximately 60–90 minutes. We audio-recorded all interviews, and they were transcribed by a professional transcription service.

The 12 interview questions that guided the study were framed by the MSJCCs’ constructs in extant literature related to the experiences of mental health counselors and clients in rural, poor communities (Bradley et al., 2012; Clark et al., 2017; Grimes et al., 2015; Grimes et al., 2013; Kim & Cardemil, 2012) and specific multicultural and social justice counseling constructs espoused in the MSJCCs (Ratts et al., 2015; Ratts et al., 2016). Six questions focused on understanding the participants’ knowledge of rural, poor communities and their experiences. Examples of these questions were: “Can you tell me the influence that persistent poverty has on the services you provide in a rural setting? What personal and client factors or experiences are influential to your work?” and “What is needed for you to competently provide counseling services to this population, if anything?” An additional six questions, also informed by the MSJCCs, sought to further explore the participant’s beliefs, skills, and actions related to multicultural competence, social justice advocacy, and counseling, such as “Can you share with me your definition and understanding of social justice advocacy in counseling? Can you share ways (if any) you incorporate social justice advocacy into your work as a counselor in a rural, economically deprived area?” and “Please share any perceived barriers to engaging in social justice advocacy and counseling in rural, economically deprived areas.”

Analysis of the data was informed by Giorgi’s (2009) and Giorgi, Giorgi, and Morley’s (2017) process for descriptive phenomenological data analysis. Specifically, we adhered to five steps in the data analysis process. First, we assumed a phenomenological attitude, in which we bracketed suppositions that could potentially influence the data and research process, such as our frustrations with perpetual deficit ideology in research related to marginalized populations. Second, after each interview was completed, we individually read each transcript to get a sense of the whole experience (i.e., native descriptions) and wrote brief notes in the margins to pinpoint any significant descriptive statements and expressions (Hays & Singh, 2012). For instance, we notated participants describing specific counseling practices that they believed were related to social justice advocacy as significant descriptive statements. We sent participants a copy of their transcript for member checking. Third, we re-read transcripts to demarcate data into multiple meaning units by clustering the invariant descriptions of participants’ experiences.

Initially, we also used a priori codes based on the MSJCCs to begin to identify units of meaning. For example, codes such as systems, advocacy, self-awareness, community, and collaboration helped us to infuse the MSJCCs’ framework and focus the findings toward understanding social justice experiences. As an example, the recognition and appreciation of a client’s ability to ascertain needed resources despite having less access and the participants’ willingness to assist in resource allocation were two invariant descriptions of experiences. The analysis process yielded 46 initial units of meaning. Participants’ quotes and definitions related to meaning units were contained in a research notebook to manage data and establish consensus coding (Hays & Singh, 2012). We held multiple meetings to discuss if and how these meaning units related to the developmental domains of the MSJCCs. For example, we discussed how one meaning unit, idiosyncrasies in the support system, closely related to the MSJCCs’ client worldview domain and reached a consensus in understanding that the participants’ ability to recognize that their clients had often strained their natural support systems exemplified that the counselor possessed knowledge of how their clients’ economic status and limited support systems shaped their attitudes and engagement in mental health treatment. In our fourth step, we reviewed the data to transform the meaning units into sensitive descriptive expressions that highlighted the psychological meaning of participants’ descriptions. We used free imaginative variation to determine the essence of the phenomenal structures of the participants’ experiences (Giorgi, 2009; Giorgi et al., 2017). We discussed any differences in understanding participants’ invariant experiences. For example, we discussed if the participants’ recognition of their need for a professional consultation to address underdeveloped counseling skills and biases related to the MSJCCs’ counselor self-awareness domain. Finally, we negotiated the interconnections and essential meanings of the meaning units, coalesced the data, and identified four essential structures that represented the descriptions of participants’ experiences and assigned them a descriptive thematic label.


Strategies for Trustworthiness

It is vital that researchers establish criteria for trustworthiness in qualitative research studies (Morrow, 2005). We demonstrated credibility through the use of bracketing, triangulation of the data sources, member checking, and peer debriefing (Morrow, 2005). Participants were provided with a copy of their transcriptions and case displays to review for member checking. We employed triangulation of data by crosschecking data (Hays & Singh, 2012) with the existing empirical studies related to rural poverty and mental health counseling. Data collection and analysis occurred concurrently in order to triangulate findings (Hays & Singh, 2012).



Using an MSJCCs lens, we identified four themes that represented the experiences of counselors who work with clients in rural poverty: (1) appreciating clients’ worldviews and life experiences, (2) counseling relationships influencing service delivery, (3) engaging in individual and systems advocacy, and (4) utilizing professional support. The findings are explicated using participants’ quotes to illustrate the meaning of each theme.


Appreciating Clients’ Worldviews and Life Experiences

Participants in the study described how they developed an appreciation for their clients’ worldviews and life experiences, even if they were different from their own. For example, Jade shared how she gained insight into and showed an appreciation for her clients’ worldviews by “showing empathy, being curious, and asking questions about what it was like for them in certain situations.” Jade expressed that seeking to understand clients’ worldviews was vital when working with African Americans living in rural poverty because she did not have the same experiences. Shelly also conveyed an appreciation for her clients’ worldviews and experiences and the impact on her clinical skills, sharing that she acquired a “different perspective” in her approach by gaining knowledge of her clients’ family structures and listening to their history.

Nine participants described that working in rural, impoverished communities entailed understanding the impact that limited resources have on providing adequate mental health services and recognizing the idiosyncrasies in clients’ support systems. Three participants described how their clients had often “burned” or “exhausted” their natural support system (i.e., personal relationships with other people that enhance the quality of one’s life), which made it difficult for participants to identify persons who would be supportive of their clients in the mental health treatment process. Addie described her counseling experiences in rural, poor communities, stating, “People have so little to fall back on, if they’re chronically mentally ill or they have a family member who is, they’re just out of resources, and they’ve maybe even burned their natural supports.” Addie further elaborated on her experiences, explaining that family members would often not return her phone calls after a client was admitted for inpatient mental health treatment.

Five participants expressed the importance of considering how low mental health literacy and mental illness stigma influenced clients’ knowledge, attitudes, and beliefs toward mental health treatment. Lola explained that she observed low mental health literacy in rural, poor communities: “There is a very low level of understanding with regard to symptoms associated with mental illness.” Lola discussed the prevalence of stigma toward clients with diagnosed mental health disorders as well as toward clients that had not been formally diagnosed because of the limited understanding of mental illness. Likewise Julian, a school-based counselor, expressed the impact of low mental health literacy in rural, high-poverty communities. Julian shared that the majority of her youth clientele were being raised by their grandparents, who had less knowledge of mental health symptoms and treatment; therefore, grandparents were often hesitant to seek mental health treatment services for their grandchildren.

Many (n = 11) of the participants indicated that in understanding the clients’ experiences and worldviews they were able to see how clients managed to be resourceful and resilient when faced with hardships. In illustration, Lola stated, “They are some of the most resourceful and resilient people that I’ve ever met; they have a knack for finding ways to achieve what needs to happen despite not having the typical resources . . . that’s very admirable.” Sue and Brenda expressed similar sentiments, also describing their clients as “resourceful.” In essence, participants explicated their attitudes and dispositions (e.g., recognizing and appreciating clients’ resourcefulness, possessing curiosity, learning about family structure and support systems) in working with clients in rural, impoverished communities. In accordance with the MSJCCs, participants expressed the importance of recognizing how the worldviews and life experiences of their marginalized clients are influenced by the context of rural poverty, such as how low mental health literacy and stigma impact the utilization of mental health treatment for this population.


Counseling Relationships Influencing Service Delivery

Participants (n = 10) described the importance of having a strong counseling relationship when working with marginalized individuals and families living in rural poverty. This solid relationship motivated participants to alter the mode of service delivery or intentionally focus more on client-centered services. Reflecting on her experiences providing home-based counseling services, Sue expressed the importance of building trust and empowerment in counseling relationships, especially when clients were involved with professionals from other agencies (e.g., probation officers) who also visited their homes. Sue described how she reinforced trust and empowerment by telling her clients, “This is about you and I’m walking alongside this path with you, I’m not going to make decisions for you.” Sue expressed that reinforcing empowerment was an essential part of counseling in rural, poor communities because clients often felt as if their power has been taken away.

Other participants shared that many of their clients came to counseling sessions without their basic needs met (e.g., food, housing, and safety) and that a solid counseling relationship allowed for more trust and openness. In return, participants expressed that clients were more willing to express their need for basic necessities without feeling ashamed, and that they often altered their services to assist clients in ascertaining immediate resources. For example, Heather noted that the poverty level was so low in her community that many of her youth clients’ basic needs were not being met and they would ask her to stop and purchase them meals. Heather disclosed that she often responded by stating, “Okay, we’re going to have to change where we’re providing therapy today, or maybe how therapy’s going to look today” to accommodate their needs. Similarly, Sadie shared, “It’s hard to see your clients going without things that you would consider basic.” Sadie described circumstances in which she arranged for food to be dropped off to the school and picked up by her clients.

Che and eight other participants acknowledged that having strong counseling relationships with clients living in rural poverty increased their willingness to extend their services beyond traditional counseling roles and settings. The participants described various cases in which they assisted clients in securing food or housing, or navigating Medicaid and other entities. For example, Che shared that she attended a mental health disability hearing with her client in which she was allowed to speak on the behalf of a client who experienced severe social anxiety. Additional participants described ways they broadened their roles to include consulting and case management and provided examples of ways they altered counseling sessions (e.g., including children because clients had no childcare) or offered incentives for attendance (e.g., bus passes and toiletries) to support clients’ continuity in treatment as well as using these as a means to help meet clients’ imminent needs. Overall, participants conveyed that their counseling relationships allowed for trust and flexibility that enabled them to use ancillary skills and knowledge when working in rural, persistently poor communities, such as skills in crisis management or intentionally building resource networks with medical professionals, churches, social service providers, law enforcement, and community organizations to help meet clients’ basic needs.


Engaging in Individual and Systems Advocacy

All participants reported engaging in various individual and systems advocacy interventions when working in rural, impoverished communities. Participants shared that engaging in advocacy was necessary, ranging from their initial sessions with their clients until termination and follow-up. George shared that he started advocacy initiatives in the initial assessment by “not jumping to assumptions” and spending more time observing clients and exploring their history. He stated that he acknowledged if clients were already taking steps toward positive change to encourage self-advocacy. George explained, “I think the most direct thing that I can do is to empower people to recognize their strengths and their rights.” Similarly, Jade shared, “I use motivational interviewing with clients to help them become better advocates for themselves.” Other participants expressed that promoting self-advocacy was vital for this specific population because of the high probability that a client would not return to counseling because of barriers related to transportation, finances, and stigma. Seven participants shared that it is important to have personal knowledge of systems that affect the client in order to inform advocacy interventions. Renee mentioned, “With all the Medicaid changes . . . I’ve got to take every client into a financial conversation. . . . So keeping myself educated . . . I can be a voice of support to them and have an understanding if they come to me.”

Additionally, participants reported various situations in which they engaged in advocacy interventions outside of the office setting. Two participants shared that they engaged in advocacy with and on behalf of clients to help them navigate the criminal justice system. For example, Jade advocated on behalf of a teenage client to law enforcement officials to request the removal of her client’s ankle monitor, which she believed was not necessary. Heather shared that she wrote letters to the courts on behalf of her clients.

Participants also discussed their involvement with helping clients sustain housing. Che shared, “I’ve spoken up for my clients against landlords who were trying to railroad several of my clients with their rent, and one in particular was trying to charge my client double the rent.” Similarly, Jade shared, “I was able to advocate to my supervisors to get funds to help pay the past bills so [clients] could move into a new location and not lose housing.”

Four participants conducted trainings in schools and within the community to inform others of culturally responsive practices with people living in rural poverty. Sadie shared that she provided educational workshops to school counselors, administrators, and teachers to help them understand the life experiences of individuals and families living in rural poverty. Sadie explained that she educated her colleagues on the effects of generational poverty and helped them to explore ways they could use various educational strategies for clients in these circumstances. Overall, counselors recognized clients’ needs and engaged in an array of advocacy interventions individually with clients, as well as in the community to support clients’ continuation in treatment, link clients to services, or help clients allocate resources in rural, poor communities.


Utilizing Professional Support

Some participants (n = 6) were the only mental health providers in the communities in which they worked. Thus, they spoke of instances of feeling frustrated because of the lack of resources for clients, role overload, and inability to connect with other counselors. Participants expressed that support from other professionals in the behavioral health field was helpful to alleviate frustrations. With this awareness, participants shared that conversations, consultations, and formalized supervision sessions were useful to explore their biases and feelings of hopelessness, to address compassion fatigue, and to learn new clinical interventions. For example, Blaze shared that formalized supervision was beneficial to increase his knowledge and improve his attitude about working in rural, impoverished communities. He stated, “The people who have supervised me understand that I’m coming from a different area and this is all kind of a learning curve. They’ve been good about helping me acclimate to the area.” Similarly, eight participants shared that ongoing supervision was helpful to abate adopting negative stereotypes and to address de-sensitization to clients’ needs, particularly when seeing clients who perpetually faced hardships. Lola discussed the benefits of having a professional support system among her colleagues to manage the demands of counseling in rural poverty. She stated, “We support each other personally when professional issues begin to impact our personal lives.” Furthermore, Lola described that ongoing supervision was “very helpful and necessary” as it provided her the opportunity to “check in” with herself and assess how she was managing the demands of her work.

Seven participants shared that receiving professional support reinforced ongoing self-awareness. For example, Sadie stated, “I think [it’s important] being willing to recognize that I’m not perfect . . . being willing to say here’s a place where I need to improve.” Sadie also expressed that it was important for her to seek supervision or personal mental health services to not allow her personal frustrations to “bleed over” into her client sessions. Likewise, Jade explained that supervision and taking continuing education credits regarding cultural differences were optimal to her success. In alignment with the constructs in the MSJCCs, the participants acknowledged the importance of engaging in critical self-reflection to take an inventory of their skills, beliefs, and attitudes (Ratts et al., 2016) that impact the services they provided to marginalized clients living in rural poverty. Overall, seeking ongoing supervision and engaging in professional development activities were necessary to prevent adopting stereotypes and to continue advocacy efforts.

Using participants’ voices and the lens of the MSJCCs, we illuminated the essence of providing mental health counseling in rural, persistently poor communities. The participants described the importance of showing an appreciation for clients’ worldviews and life experiences and how their counseling services encompassed varied approaches to service delivery and non-traditional counseling methods to engage rural, impoverished clients in the treatment process. Participants frequently engaged in individual and systems advocacy with and on behalf of their clients and described how having professional support was necessary to provide culturally responsive mental health counseling in rural, persistently poor communities. The findings serve as the basis for the following discussion.



This study explored the experiences of mental health counselors working in rural, impoverished communities and identified ways counselors incorporated social justice advocacy using the lens of the MSJCCs to identify advocacy skills and interventions. We found that counselors who work with clients in rural poverty appreciate their clients’ worldviews and life experiences, value their counseling relationships, alter service delivery formats, engage in advocacy, and seek ongoing professional support and development opportunities. Specifically, the first theme captured how counselors in the study expressed an appreciation for their clients’ worldviews and life experiences, as described in the MSJCCs’ client worldview domain. Counselors recognized that various contextual factors, such as family structure, nuances in the natural support systems, less access to resources, as well as how race and social class status shaped their clients’ worldviews, influenced their utilization of mental health treatment. This finding lends support to previous literature associated with examining how economic disadvantages and rurality influence mental health care services and literacy (Deen & Bridges, 2011; Kim & Cardemil, 2012). Consistent with the MSJCCs’ (Ratts et al., 2015) client worldview domain, the counselors explored and appreciated clients’ history and life experiences, and acknowledged the clients’ “resourcefulness” as a strength.

Furthermore, counselors in the study expressed a willingness to engage in their clients’ personal communities, which aligns with the suggestion in the client worldview domain that counselors should immerse themselves in the communities in which they work to learn from and about their clients (Ratts et al., 2015). The findings from the study correspond to previous research that examines how counselors with increased exposure to individuals living in poverty have enhanced multicultural competence and are able to critically examine systemic or structural factors that contribute to the underutilization of mental health services in high-poverty communities (Clark et al., 2017).

The second theme, counseling relationships influencing service delivery, reflected the MSJCCs’ counseling relationship domain. Participants recognized that their clients’ ability to engage in the traditional therapeutic process was often thwarted because many of their clients’ basic needs were not met. As implied in the counseling relationship domain, counselors are advised to utilize culturally competent assessment and analytical and cross-cultural communication skills that allow them to effectively determine clients’ needs and employ collaborative, action-oriented strategies to strengthen the counseling relationship (Ratts et al., 2015).

Reflective of this domain, counselors in the study often altered service delivery formats and assumed alternative roles to meet clients’ needs. The current findings offer support for research that advances increasing flexibility in counseling roles and culturally competent assessments when working in marginalized communities (Fifield & Oliver, 2016).

Another distinctive finding of this study was encompassed in the third theme, which captured the MSJCCs’ counseling and advocacy interventions domain, and illuminated the participants’ use of strategies to promote continuation of services (e.g., home-based counseling, group formats with the inclusion of childcare, and distributing incentives) as well as advocacy interventions to address clients’ imminent needs. Expanding previous research that illuminated the role of self-advocacy (Singh, Meng, & Hansen, 2013), the participants expressed the importance of engaging in intrapersonal, interpersonal, and institutional advocacy interventions with and on behalf of clients, such as assisting clients in securing or maintaining housing, acquiring supportive educational resources in school settings, rebuilding familial relationships, and preventing the criminalization of poverty. Although these findings are similar to previous researchers’ perspectives that suggest that counseling in rural poverty requires counselors to engage in various advocacy roles (Kim & Cardemil, 2012; Reed & Smith, 2014), this study answers the call to provide practical examples of incorporating social justice advocacy into counseling with historically marginalized populations (Ratts & Greenleaf, 2018).

The final theme identified in our study involved the participants’ use of professional support networks and seeking professional development opportunities to address areas of professional incompetence. Accordingly, this theme aligns with aspects in the MSJCCs’ self-awareness domain. As articulated in this domain, multiculturally competent counselors are expected to have an awareness of their social group statuses, power, privilege, and oppression, as well as acknowledge how their biases, attitudes, strengths, and limitations may influence clients’ well-being (Ratts et al., 2015). The counselors in our study engaged in both informal and formal action-oriented strategies, such as consultations and ongoing supervision with other mental health professionals, that helped them examine prejudicial beliefs, prevent the development of additional biases, and explore other areas of vulnerability and skills deficiencies as designated in the MSJCCs’ counselor self-awareness domain. This finding supports past research (Bowen & Caron, 2016; Reed & Smith, 2014) that indicated that because of the limited resources and remoteness in rural, impoverished areas, professional support is vital to assuage frustrations because of consistently seeing poor, rural clients navigate difficult life circumstances. However, this finding expands current understanding by focusing on the counselors’ ability to identify their own limitations and readily seek out additional supports.


Implications for Counseling Practice, Advocacy, and Training

Foremost, in order to offer culturally competent mental health counseling, it is important for counselors to appreciate their clients’ worldviews and life experiences and understand the unique oppressions that clients from rural, impoverished communities experience. For example, participants acknowledged that various contextual factors, such as family structure, mental illness stigma, and nuances in the natural support systems, shaped their clients’ worldviews and influenced their utilization of mental health treatment. Viewing clients’ concerns from a socioecological lens may strengthen the counselor–client relationship (Ratts et al., 2016) and decrease stigma related to mental health treatment (Stewart et al., 2015).

Counselors also must be flexible and recognize that altering the format of session delivery is often necessary to engage with clients in rural poverty. Individuals living in rural poverty face immense financial barriers that impede the utilization of mental health treatment (e.g., transportation issues), and there is a general lack of awareness about mental illness in rural, poor communities (Haynes et al., 2017). Thus, counseling in rural poverty should extend beyond office-bound interventions to include community-based interventions (Ratts & Greenleaf, 2018) and account for barriers that influence treatment utilization. For instance, the findings indicated that participants had a greater appreciation for clients’ worldviews and expanded their roles to include consulting, advocacy, and case management when they became more engaged in their clients’ personal environment and community.

Furthermore, counselors in this study collaborated with and on behalf of clients in advocacy efforts in various areas such as housing, criminal justice, social services, and school systems. Engaging in individual- and systems-level advocacy interventions (Ratts et al., 2016) when working in rural, impoverished communities is vital to promote equity and positive systemic changes (Reed & Smith, 2014). Given these findings, counselors should become comfortable with professionals in these areas as well as going into the respective environments. Thus, it warrants counselors to network with community partners, schools, faith communities, and law enforcement entities to establish relationships to enhance support networks. In addition, writing letters to federal and state legislators regarding national issues such as Medicaid funding is critical to address policies that benefit rural, impoverished communities.

Finally, multicultural and social justice competence is a developmental process, and professional counselors as well as counselors-in-training need opportunities for ongoing self-reflection to examine their personal assumptions and biases and enhance their skills when working with rural, impoverished communities. Clinical supervision grounded in a social justice framework can help counselors and supervisors process their biases and assumptions, develop a social justice lens of understanding clients from rural poverty, and cultivate advocacy skills (Smith et al., 2013). The MSJCCs should be facilitated throughout counseling program curricula versus one foundation course in multicultural counseling and development. Some possibilities for incorporating the MSJCCs into student learning across all courses include experiential activities, group work, and role-plays that cover topics such as worldviews, intersecting identities, power, privilege, and social class. For example, audiovisual materials found on the Rural Health Information Hub website ( can help students visualize the experiences of rural and impoverished communities. Additionally, encouraging or requiring counselors-in-training to engage in rural, economically disadvantaged communities for their practicum and internship experiences can be incorporated into the clinical sequence in counselor preparation programs


Recommendations for Future Research

There are several pathways to advance research pertaining to mental health counseling and social justice advocacy in rural poverty. Rural, impoverished areas continue to experience low mental health literacy, which perpetuates stigma. Thus, investigations about stigma in rural poverty can provide insights into the underutilization of mental health treatment in rural communities. Research of various designs regarding the lived experiences of poor women, men, and children in rural communities can inform culturally responsive counseling practices. For example, empirical studies about the experiences of grandparents raising grandchildren in rural poverty can offer unique perspectives for ways to enhance mental health literacy and increase utilization of mental health services. Additional studies are also needed to explore social justice advocacy interventions that are necessary to test the efficacy of the MSJCCs.

Finally, a primary limitation of this study was that the participants had varied professional license levels, areas of specialization, years of professional experience, and provided counseling services to diverse clientele in various settings. The data in the current study did not allow us to assess if variances in the noted areas had a differential impact on the participants’ counseling experiences in rural poverty. Consequently, additional qualitative studies that allow researchers to examine these differences more pointedly are needed to fully understand the experiences of counselors from varied backgrounds and experience levels. Furthermore, readers should exercise caution when generalizing the experiences of the 15 participants in this sample to other counselors working in rural, impoverished communities. The experiences of participants in this sample may not capture the experiences of all counselors working in these communities; however, readers can make decisions regarding the degree to which the findings of the study are applicable to the settings in which they live and work (Hays & Singh, 2012).



Poverty significantly impacts the mental health of children and adults living in rural communities, resulting in having limited access to resources and services that can promote healthy development and well-being. Therefore, mental health counselors working in rural, poor communities must often incorporate social justice advocacy within the context of clients’ experiences of oppression in their counseling practices to provide culturally responsive services. The MSJCCs provided a lens to explore the knowledge, skills, beliefs, and overall practices of 15 professional counselors working in rural, impoverished communities. By examining the experiences of these counselors, we identified how counseling professionals working in rural, impoverished communities acknowledged and appreciated their clients’ worldviews and life experiences, created strong therapeutic alliances, altered counseling service delivery, engaged in advocacy, and sought professional support to sustain their ability to provide culturally responsive counseling services. Multiculturally competent counselors should continually explore ways to amend their current practices to address the various sociocultural barriers that impede the mental health and well-being of rural, poor children and adults. It is our hope that counselors will utilize the findings from this study to further the discourse on rural poverty and create positive change in these communities.


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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Loni Crumb is an assistant professor at East Carolina University. Natoya Haskins is an associate professor at the College of William and Mary. Shanita Brown is an instructor at East Carolina University. Correspondence can be addressed to Loni Crumb, 213B Ragsdale Hall, Mail Stop: 121, Greenville, NC 27858,

Ageism and the Counseling Profession: Causes, Consequences, and Methods for Counteraction

Matthew C. Fullen

As the number of older adults increases, it is important to understand how attitudes toward aging influence society, the aging process, and the counseling profession. Ageism—defined as social stigma associated with old age or older people—has deleterious effects on older adults’ physical health, psychological well-being, and self-perception. In spite of research indicating that the pervasiveness of ageism is growing, there are few studies, whether conceptual or empirical, related to the impact of ageism within the practice of counseling. This article includes an overview of existing literature on the prevalence and impact of ageism, systemic and practitioner-level consequences of ageism, and specific implications for the counseling profession. Discussion of how members of the counseling profession can resist ageism within the contexts of counselor education, gerontological counseling, advocacy, and future research will be addressed.

Keywords: ageism, aging, older adults, gerontological counseling, advocacy

Currently, there are approximately 47.8 million adults age 65 and over living in the United States, and this number is expected to grow to 98 million—or more than one in five Americans—by 2060 (Administration on Aging, 2017). Much of this growth can be attributed to the aging of the boomer generation, the age cohort born between 1946 and 1964. Approximately 10,000 boomers turn 65 every day (Short, 2016). Increases to the average life span also have expanded the number of older Americans, with a person age 65 now living an average of 19.4 additional years, and many living well beyond that age (Administration on Aging, 2017). Nonetheless, many misconceptions remain about the aging process, and recent research demonstrates that the prevalence of ageism is growing (Ng, Allore, Trentalange, Monin, & Levy, 2015). Ageism—defined here as social stigma related to old age or older people (Widrick & Raskin, 2010)—is associated with the lack of mental health services available to older adults (Bartels & Naslund, 2013), and when negative attitudes toward aging are internalized by older adults, significant consequences to health and well-being may occur (Levy, 2009).

Within the counseling literature, there appears to be a lack of research on ageism and its impact on older adulthood. A keyword search of leading counseling journals dating back to 1992 results in a single publication on the topic of ageism within the American Counseling Association’s Journal of Counseling & Development (Saucier, 2004), as well as a single empirical study in Adultspan Journal (McBride & Hays, 2012). Therefore, to elucidate the effects of ageism, as well as its role within the field of professional counseling, this article will provide a review of existing literature on the prevalence of ageism, its consequences among mental health professionals, and the impact of internalized ageism on older adults. The article concludes with recommendations for how counselors, counselor educators, and counseling students can mitigate the effects of ageism and promote positive perceptions of aging.


Prevalence and Impact of Ageism

Prevalence of Ageism

The term “ageism” was first used in the late 1960s to describe discriminatory beliefs or practices that are predicated on the age of a person or group (Butler, 1969). Like racism or sexism, prejudice associated with age is both pernicious and challenging to quantify. Many myths about aging are assumed to be true without additional consideration, leading to a “commonsense reality” about old age or older people that is then perpetuated throughout a society (Angus & Reeve, 2006, p. 141). Moreover, scholars argue that ageism is currently met with less disapproval than racism or sexism (Cuddy & Fiske, 2002; Nelson, 2016; Palmore, 2005), although more recent empirical research is needed to substantiate this hypothesis. Nevertheless, research indicates that views about aging are becoming more negative (Ng et al., 2015). Dominant myths include the notion that older adults are: (a) lonely and depressed; (b) increasingly similar as they grow old; (c) sick, frail, and dependent; (d) cognitively and psychologically impaired; (e) sexless and boring; and (f) unable to learn or change (Thornton, 2002; Whitbourne & Sneed, 2002). These myths persist in spite of research that demonstrates that older adults are heterogeneous, possess many psychosocial resources, frequently have high levels of self-rated and objectively measured health, and mostly do not experience dementia or other forms of cognitive impairment (Whitbourne & Sneed, 2002).

Stereotypes about older adulthood are transmitted throughout society and may lead to detrimental consequences for the health and well-being of older people. For example, media representations of older adults are likely to reinforce negative views about older adulthood. Television shows, movies, and advertising depict older people according to stereotypes about aging—or omit them altogether (North & Fiske, 2012)—and older people who watch more television over the course of their lives tend to view aging in a more negative light (Donlon, Ashman, & Levy, 2005). Ageism is transmitted through social media as well. References to older adults on Facebook are commonly comprised of references to cognitive or physical debilitation, the infantilization of older people, or suggestions that older adults be banned from public activities like driving or shopping (Levy, Chung, Bedford, & Navrazhina, 2014).

Negative stereotypes may lead to age-based discrimination, a phenomenon that experts describe as both “understudied” and “surprisingly pervasive” (North & Fiske, 2012, p. 983). For example, Posthuma and Campion (2009) described several workplace-based stereotypes that exist, in spite of a lack of supporting evidence. These include the notion that older workers have lower levels of ability and motivation, lower productivity, and greater resistance to change. Within the realm of health care, physicians may be less likely to offer particular medical treatments to older patients because of a belief that certain ailments are the inevitable consequences of natural aging (Bowling, 2007). Ageism may result in elder abuse, both within care facilities and among family members; however, it is underreported because of a lack of awareness among health and social service providers (Nelson, 2005).

Negative stereotypes about aging develop in a manner that parallels stereotypes like racism or sexism. Levy’s (2009) stereotype embodiment theory suggests that ageist views may be transmitted culturally and internalized by older adults, leading to significant changes to health and functioning. Older adults are first exposed to negative stereotypes about aging when they are young. As individuals age into older adulthood, their negative beliefs about aging become increasingly salient and self-directed. On the other hand, if an individual is socialized to hold more positive views toward aging, these viewpoints may serve as a buffer against internalized ageism (Levy, 2009).

Furthermore, stereotype embodiment theory (Levy, 2009) suggests that when stereotypes are assimilated from the surrounding culture, they eventually become self-definitions that influence a person’s functioning and health. Stereotype embodiment theory concludes that: (a) stereotypes are internalized throughout the life span; (b) they are likely to operate unconsciously; (c) as views of older age become increasingly relevant to a person’s identity, the age stereotypes become more salient; and (d) self-referential views on aging are developed via pathways that may be both top-down (i.e., societal perspectives are passed on to the individual) and longitudinal (i.e., views on old age begin in childhood).

Cuddy, Norton, and Fiske (2005) argued that groups within a society are often categorized based on two traits—warmth and competence—and the authors found that most participants rated older adults as warm, but incompetent. Contrary to the belief that ageism is only a concern in Western countries, Cuddy et al. reviewed a large-scale international study that included college students in Belgium, Costa Rica, Hong Kong, Japan, and South Korea. Across samples, participants viewed older adults as significantly more warm than competent, non-competitive, and having lower social status. Within their study, this trend persisted even when looking at cultures and countries that are typically described as more collectivist (i.e., Hong Kong, Japan, and South Korea).

Research indicates that ageism is prevalent within environments where older adults receive housing and health care services. In an ethnographic study on the impact of age and illness within a residential care setting, Dobbs et al. (2008) found that some family members, staff, and residents held negative attitudes about aging that resulted in an environment affected by ageism. In their study, examples of negative age bias included neglecting to gather resident input prior to making decisions, using infantilizing speech with older people, and stigmatizing residents because of dementia or physical disability. In a similar study completed within a multi-level care setting, Zimmerman et al. (2016) found that the use of multi-level, stepped care (i.e., adults with differing independence levels residing within the same setting) reinforced stigma related to age and health, with older adults differentiating among themselves based on which levels of care were required.


Impact of Social Forces

Scholars posit a wide range of hypotheses to explain the prevalence of ageism, but two systemic processes—modernization and medicalization—are identified in the literature as the most likely catalysts of negative attitudes toward aging (Cuddy & Fiske, 2002; Ng et al., 2015). In regard to modernization theory, Cuddy and Fiske (2002) explained that views of older adulthood have changed as a result of the shift from an agrarian society to an industrial society. Technological advances, increased literacy rates among young people, and a trend toward urbanization resulted in greater competition between young and old generations, as well as weakened intergenerational social ties between young people and their families of origin. The sum of these social changes led to decreased status for older people, resulting in the “warm, but incompetent” stereotype that is now associated with them (Cuddy et al., 2005).

Relatedly, improvements in health care have extended the life span and increased the ratio of older to younger people. Previous research shows that as the ratio of older adults to younger adults increases, views about older adulthood become increasingly negative (Ng et al., 2015). Given that the number of older people will increase markedly in coming years, it is possible that negative attitudes toward older people will continue to grow unless intervention occurs.

The second major social force described in the literature is the medicalization of aging, which refers to associating old age with a person’s physical health or illness, to the detriment of other aspects of well-being (Ng et al., 2015). The dominance of medical conceptualizations of old age is described as one of the “master narratives” associated with the modern study of aging (Biggs & Powell, 2001, p. 97). Although the causes of medicalization are many and complex, they can be summarized by the shift from viewing old age as a natural part of the life span to the viewpoint that old age, and even death itself, are problems that modern medicine may be able to solve (Ng et al., 2015). Past research indicates that the medicalization of aging predicts negative attitudes toward aging and consequentially leads to “the objectification of older adults as patients rather than as individuals with interesting life experiences” (Ng et al., 2015, p. 2).


Consequences of Ageism


Impact on Older Adults’ Health and Well-Being

There is a substantial body of research indicating that age stereotypes influence older adults’ health and well-being. For instance, older adults’ perceptions of aging are associated with memory performance (Levy, Zonderman, Slade, & Ferrucci, 2011), hearing decline (Levy, Slade, & Gill, 2006), developing Alzheimer’s symptoms (Levy et al., 2016), and dying from respiratory or cardiovascular illnesses (Levy & Myers, 2005). In fact, Levy, Slade, Kunkel, and Kasl (2002) found that even after controlling for age, gender, socioeconomic status, loneliness, and functional health, older adults with more positive self-perceptions of aging lived 7.5 years longer than those with less positive self-perceptions of aging.

Conversely, research indicates that positive perceptions of aging may provide a salutatory effect on health and well-being. Older adults with positive age stereotypes are 44% more likely to fully recover from severe disability compared to those with negative age stereotypes (Levy, Slade, Murphy, & Gill, 2012), and older military veterans who resisted negative age stereotypes had significantly lower rates of mental illness compared to those who fully accepted them (Levy, Pilver, & Pietrzak, 2014). These positive differences were found for suicidal ideation (5.0% vs. 30.1%), anxiety (3.6% vs. 34.9%), and PTSD (2.0% vs. 18.5%), even after controlling for age, combat experience, personality, and physical health. In regard to variables that may influence older adults’ self-perceptions of aging, Fullen, Granello, Richardson, and Granello (in press) found that resilience—the ability to bounce back from adversity—and multidimensional wellness were significant predictors of positive age perception, whereas increased age and decreased physical wellness predicted internalized ageism. Furthermore, resilience appeared to buffer older adults from experiencing internalized ageism as they grew older. However, older adults may not be exposed to interventions to promote resilience and well-being because of ageism’s impact on the availability of mental health services among older adults.


Impact on Mental Health Professionals

The gap between the mental health needs of older adults and the number of mental health professionals with specific training in working with older adults is on the verge of a “crisis” (Institute of Medicine, 2012, p. ix). Scholars provide a variety of explanations to account for this, including systemic factors—such as inadequate funding and a lack of training opportunities within academic programs (Bartels & Naslund, 2013; Gross & Eshbaugh, 2011; Robb, Chen, & Haley, 2002)—and personal factors, including low interest in working with older adults (Tomko, 2008) and therapeutic pessimism (Danzinger & Welfel, 2000; Helmes & Gee, 2003).

Systemic ageism. Although older adults consistently report higher life satisfaction than younger or middle-aged adults (George, 2010), approximately 26% of all Medicare beneficiaries, or more than 13 million Americans, meet the criteria for a mental disorder (Center for Medicare Advocacy, 2013). Yet, mental health services currently account for only 1% of Medicare expenditures (Bartels & Naslund, 2013). Systemic barriers may be partially responsible for the lack of access to mental health services among older adults. For example, inadequate reimbursement rates is cited as one reason for the 19.5% decline in psychiatrists accepting Medicare between 2005–2006 and 2009–2010 (Bishop, Press, Keyhani, & Pincus, 2014). Similarly, Medicare payments to psychologists for psychotherapy decreased by 35% since 2001, after adjusting for inflation (American Psychological Association, 2014). Older adults are currently unable to use Medicare to access services provided by licensed professional counselors (LPCs) or marriage and family therapists (MFTs; Fullen, 2016b). This translates to an estimate of 175,000 mental health professionals who are unavailable to serve as Medicare-eligible providers (American Counseling Association, n.d.). Clients who age into Medicare coverage after working with these professionals face discontinuity of care caused by having to change providers.

Professional training barriers among the helping and health professions also may reflect systemic ageism. Half of the fellowship positions in geriatric medicine and geriatric psychiatry are unfilled each year, and only 4.2% of psychologists focus on geriatric care in clinical practice (Bartels & Naslund, 2013). Institutional barriers that inhibit student interest in careers related to work with older adults include a lack of visibility for multidisciplinary gerontology programs, the absence of gerontological content within textbooks, few faculty who are trained in gerontology, misconceptions about employment opportunities (i.e., the assumption that the only aging sector jobs available are in nursing homes), and a primary focus on the problems associated with old age when later life is discussed within the classroom (Gross & Eshbaugh, 2011).

Within the counseling profession, scholars describe a mixed commitment to gerontological counseling. Going back to 1975, Salisbury (1975) and Blake and Kaplan (1975) described counseling with older adults as an overlooked domain within professional counseling. Twenty years later, Myers (1995) argued that gerontological counseling had evolved from “forgotten and ignored” (p. 143) to a sub-discipline within the profession complete with standards and certification. However, the gerontological counseling specialization that existed between 1992 and 2008 was discontinued in 2009 when only two institutions had applied for accreditation (Bobby, 2013). Perhaps more telling, the 2016 Standards of the Council for Accreditation of Counseling & Related Educational Programs (CACREP) include zero references to the words old, older, older adults, or ageism; only one reference each to the words age and aging; and four references to the phrase life span (CACREP, 2015). Nonetheless, Foster, Kreider, and Waugh (2009) found that many counseling students have interest in topics related to gerontological counseling, including grief counseling (70%), retirement counseling (43%), family counseling with aging parents (64%), and counseling caregivers (55%). The same study found that many respondents were interested in working in a hospice setting (39%), a hospital geriatric unit (29%), a nursing home (25%), private practice with older adults (43%), and a community setting with older adults (45%). However, it is unclear whether students who are interested in working with older adults receive training and employment opportunities within these contexts.

Individual ageism. Research regarding the prevalence of ageism among individual mental health professionals is equivocal. When mental health professionals’ perceptions of clients based on age, gender, and health variables were studied, some researchers found health bias, but not age bias (Robb et al., 2002). Others reported that participants rated older clients as having a greater number of diagnostic problems (Helmes & Gee, 2003) and a worse prognosis than younger clients, in spite of all relevant information being matched across age groups (Danzinger & Welfel, 2000). Helmes and Gee (2003) found large differences in how older people were rated on key therapeutic variables. Older clients were viewed as less able to develop an adequate therapeutic relationship, less appropriate for therapy, and less likely to recover. Respondents in their study also felt less competent in treating older people, and they were less willing to accept older people as clients.

To counteract the potential influence of negative age bias on counseling treatment, McBride and Hays (2012) described the importance of linking work with older adults to multicultural competence. The authors surveyed 360 counselors and counselor trainees and found a significant, negative correlation (r = -.41) between multicultural competence and negative attitude toward aging. Tomko (2008) found that multicultural competence was associated with improved clinical judgment when working with older adults; however, it did not predict global attitudes toward aging. In sum, considerations of both the systemic and individual aspects of ageism have important implications for the counseling profession.


Implications for the Counseling Profession

The rapid growth of the older adult population will impact members of the counseling profession in a variety of ways. Shifting age demographics make it imperative that counselors understand how the pervasiveness of ageism impacts key professional values like diversity, social justice, and client advocacy. Four domains are outlined in which counselors may dedicate their attention to generating positive views of aging. These domains include counselor education, advocacy, research, and counseling practice.


Counteracting Ageism Within Counselor Education

Within counselor training programs, resistance to ageism begins with incorporating discussions about aging and older adulthood into the counselor education curriculum. Therefore, it is important that professional accreditation standards like CACREP adequately reflect the mental health needs of older adults and their families. In its current form, the omission of keywords like aging, older adulthood, and ageism from these standards may send a mixed signal to counselor training programs and their students about social justice and multicultural competencies as they relate to older adults.

Once ageism is identified by a counselor education program as a priority, counselor educators need to develop strategies for incorporating this focus in the existing curriculum. For instance, a life span development course provides ample opportunities to discuss issues such as shifting population demographics, multigenerational families, and how an aging population will impact the counseling profession. Assessing students’ current thoughts about the aging process, including both their own aging and that of family members, may create greater empathy for the needs of older adults. Similarly, when instructing social and cultural diversity courses, counselor educators should consider introducing topics such as ageism and age privilege and juxtaposing these constructs alongside dialogue about diversity and intersectionality (Black & Stone, 2005). Furthermore, when developing practicum or internship sites, counselor educators could make a point of developing placements in which older clients will be served. Identifying potential site supervisors who have experience in working with older adults is an important step, as it ensures that trainees are given adequate opportunities to reflect on their own perspectives on aging, disability, advocacy, and related issues.


Counteracting Ageism Through Advocacy

In regard to advocacy, counselors should resist ageism at national, state, and local levels. At the national level, the omission of counselors as approved Medicare providers limits the availability of mental health services for older adults and reflects the assumption that older adults’ needs are primarily physiological. This issue creates challenges for members of the counseling profession who are interested in providing services across the life span. Mental health advocacy on behalf of older adults includes educating lawmakers about the importance of Medicare reimbursement as a means of creating mental health service access (Fullen, 2016b). Professional organizations continue to support grassroots advocacy, as well as lobbying efforts, to influence Medicare policy on behalf of counselors. In fact, as of this writing there are bills in each chamber of the United States Congress (i.e., S. 1879; H.R. 3032), and a federal advisory group (i.e., the President’s Interdepartmental Serious Mental Illness Coordinating Committee; ISMICC) recently recommended inclusion of counselors within Medicare (National Board for Certified Counselors, n.d.).

At the state and local level, members of the counseling profession should forge partnerships with gerontology professionals. For example, advocacy occurs when professional counselors and counselor educators make connections with members of the local area agency on aging, directors of local assisted living or skilled nursing facilities, or state policymakers who are responsible for budgetary and policy decisions related to aging. These partnerships are mutually beneficial; they provide members of the counseling profession with increased exposure to the diverse needs of older adults in their communities, and they educate local gerontology professionals about the range of mental health services that counselors provide. Additionally, building interprofessional connections may lead to research opportunities that can improve the care received by older adults.


Counteracting Ageism Through Research

In spite of the numerous studies indicating that ageism has detrimental effects on older adults, there are currently very few studies that demonstrate the prevalence and impact of ageism within the counseling profession. For instance, research on in-session dynamics between counselors and much older clients could shed light on the ways in which age is broached in a counseling session. Additionally, research could focus on the benefits of professional counseling for older adult clients, as well as the effectiveness of novel interventions that are grounded in counseling theories or wellness (Fullen & Gorby, 2016; Fullen et al., in press). For instance, the development and validation of a wellness-based approach to counseling older adults might mitigate mental health issues or internalized ageism among older clients (Myers & Sweeney, 2005), and it would serve as additional evidence for the necessity of adding counselors as Medicare providers.

At the institutional level, more research is needed to understand the extent to which counselor training programs address ageism, and in which curricular contexts. It is important to understand which pedagogical strategies are most effective, whether these impacts persist over time, and how well training programs make inroads with local agencies that work with older adults. Research into advocacy efforts related to Medicare reimbursement may also advance the profession. Although Medicare reimbursement is described as a priority for the counseling profession, there is currently little research on counselors’ knowledge about Medicare or participation in Medicare advocacy.


Counteracting Ageism Through Counseling Practice

Finally, it is important to consider how counselors might resist ageism within their counseling practice. Because of the heterogeneity of older adults, counseling services should be tailored to the unique needs of each client. Given that ageism has the potential to influence how older clients are conceptualized by counselors, it is important for counselors to reflect on their own beliefs about aging as well as their assumptions about the ability of older clients to grow and change. Many counselors are not familiar with the wide range of mental health interventions that have been empirically validated with older adults (Myers & Harper, 2004). For example, the SAMHSA-HRSA Center for Integrated Health Solutions (n.d.) provides numerous resources related to providing behavioral health services to older adults. These resources address issues such as evidence-based treatments for late life depression, preventing suicide in older adults, screening for substance misuse, and assessing cognitive functioning.

Given the growing interest in wellness-oriented services for older adults, SAMHSA also provides evidence-based resources related to health promotion and integrated care. Programs that focus on cultivating holistic wellness or resilience are relatively new, but they also may be worth considering as a means of countering ageism within the practice of counseling. Because the wellness approach incorporates multiple dimensions of functioning, older clients who are experiencing deficits in a particular domain (e.g., limited mobility influencing ability to drive) may find that they can use alternative domains as a means of compensating (e.g., greater reliance on social network to carpool to events; Fullen, 2016a). Similarly, discussion of how older clients have used strengths to navigate loss, overcome adversity, and resist ageism in their own lives may prove to be key ingredients in the therapeutic process. Furthermore, incorporating resilience into an older client’s treatment plan may create a buffer against internalized ageism (Fullen et al., in press), as well as an opportunity to highlight older adults’ abilities to adapt in the face of adversity (Fullen & Gorby, 2016).




As the number of older adults grows, members of the counseling profession are increasingly likely to encounter older people who seek to benefit from counseling services. A review of existing research demonstrates that there are numerous causes of ageism, detrimental consequences associated with internalizing negative age stereotypes, and gaps in research related to how the counseling profession should respond. In light of the counseling profession’s commitment to diversity, social justice, and advocacy, it is important to better understand the broad impact of ageism. By combating ageism in the domains of public policy, research, teaching, and direct service with clients, members of the counseling profession have the opportunity to counteract ageism’s deleterious effects and promote more positive perceptions of growing older.


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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Enhancing the Sport Counseling Specialty: A Call for a Unified Identity

Stephen P. Hebard, Katie A. Lamberson

Athletes represent a unique population with a legitimate need for counseling services; yet, counselors have done little to define and promote sport counseling. This paper represents a call to counselors, educators, and researchers to advocate for a rigorous sport counseling specialization and clarified professional identity. Counselors need to identify required competencies, teaching guidelines, and ethical codes to provide optimal mental health services to athletes and effectively co-exist among other professionals in sport. The current state of mental health services for athletes, the potential for counselors to provide unique contributions to mental health in sport, and actionable steps regarding advocacy and research are discussed.

Keywords: sport counseling, professional identity, advocacy, athletes, mental health


Athletes represent a considerable segment of the American population. As of 2016, 40% of youth aged 6 to 12 participated in team sports, a 3% increase from 2015 (Rosenwald, 2016). Recent surveys show that 8 million high school students play sports (National Federation of State High School Associations, 2015), about 525,000 participate at the collegiate level (National Collegiate Athletic Association [NCAA], 2017a), and more than 11,800 are considered elite, professional athletes (Bureau of Labor Statistics, 2014). Over the past several years, researchers have recognized that athlete mental health concerns often go largely unaddressed (Ferrante & Etzel, 2009; Nattiv, Puffer, & Green, 1997).

Athletes at every level are often perceived to be privileged and idolized for their physical prowess; however, this perception leaves them especially vulnerable to be missed when it comes to mental health concerns. In fact, as a population, athletes are described as “at-risk” of experiencing a multitude of mental health concerns. Researchers have demonstrated that athletes are susceptible to alcohol abuse (B. E. Miller, Miller, Verhegge, Linville, & Pumariega, 2002), lower levels of wellness than non-athletes (Watson & Kissinger, 2007), risky behaviors (Nattiv et al., 1997), depression (Nixdorf, Frank, Hautzinger, & Beckmann, 2013; Storch, Storch, Killiany, & Roberti, 2005; Yang et al., 2007), social anxiety (Storch et al., 2005), eating disorders (Currie & Morse, 2005), and aggression (Benedict & Yaeger, 1998), among other mental health issues. Many of these mental health concerns may result from the demands and pressures experienced by athletes. For example, some athletes have been found to over-train, which may result in depression, decreased self-esteem, or emotional instability (Raglin & Wilson, 2000). Furthermore, athletes are less likely to seek professional help than their non-athlete counterparts for mental health concerns (López & Levy, 2013; Watson, 2005). Given the growth of sport from youth to adulthood and the challenges to mental health inherent in sport participation, mental health professionals can provide support to athletes that is currently lacking. However, in order to deliver optimal care, mental health professionals must commit themselves to fully understanding the athlete experience.

Counselors are in a position to provide unique, culturally responsive mental health services to athletes; however, the profession’s presence in sport is limited due to a poorly defined professional identity and a lack of understanding of the unique skill set counselors possess. A lack of empirically derived competencies, teaching guidelines, and ethical considerations must be addressed if sport counselors hope to have a greater presence in sport. Additionally, competition with sport psychologists, who primarily address athletic performance optimization and are currently far more integrated into athlete culture, may be a barrier for counselors. However, because sport psychologists primarily educate athletes on mental skills for performance optimization and counselors directly address mental health concerns, there is room for these professionals to work together to address the overall wellness and performance needs of athletes.

The purpose of this paper is to discuss the current state of mental health services provided to athletes and to identify and address the potential barriers for counselors who wish to work in sport. In addition, the authors will provide a brief history of a vision for an integrated sport counseling specialty, gaps in counselor competence and identity necessary to establish sport counseling among widely recognized professions in sport, and suggestions for researchers, practitioners, and advocates to ensure a future for the sport counseling specialty.


The Evolution of Mental Health Services in Sport

The unique challenges of athletes were first identified in the early 1970s by a group of college counselors that would later form the National Association for Academic Advisors of Athletics (N4A; National Association of Academic and Student-Athlete Development Professionals, 2017). Their commitment to encouraging student athlete academic achievement led to an expansion of their initiative beyond academics and a moniker representative of their current mission (the National Association of Academic and Student-Athlete Development Professionals). N4A’s impact is experienced by over 40,000 athletes annually, as the organization was integral in the development of the NCAA’s CHAMPS/Life Skills (now NCAA Life Skills) program. N4A and the NCAA Life Skills program define their commitment as one that impacts athlete academic achievement, athletic performance, and personal well-being. Although there is little doubt that these programs positively impact athletes, their focus is not specific to mental health. In fact, until the early 2010s, sport organizations had done little advocacy for athletes experiencing mental health challenges. In 2013, the National Athletic Training Association (NATA) made a call for mental health practitioners to help increase mental health awareness within athletics organizations (Neal et al., 2013). NATA published recommendations for athletic trainers, who are considered the “first responders” to both physical and mental health (Burnsed, 2013a), to develop a collaborative plan to recognize and refer student athletes experiencing psychological concerns to the appropriate mental health professionals. In doing so, NATA catalyzed a long overdue shift in the philosophy and attention of stakeholders invested in the overall well-being of athletes. Soon thereafter, the NCAA (2014) recruited a Mental Health Task Force to demonstrate substantial commitment to the prioritization of mental health concerns experienced by student athletes. This task force is committed to working with coaches, medical providers, and student athletes to address the stigma commonly associated with mental health issues and how to break through barriers to mental health access (Burnsed, 2013b). Despite the positive goals the NCAA aims to achieve, counselors have yet to be represented on this task force.

Similar to these shifts at the collegiate level, professional organizations have made some strides toward recognizing the mental health needs of their athletes. For example, the National Football League (NFL)-affiliated Player Engagement Division currently provides active players with the “NFL Life Line.” The NFL Life Line is a crisis hotline for current and former NFL players that offers independent, confidential support (NFL Life Line, 2016). The actions of NATA, the NCAA, and the NFL represent a significant investment in athlete mental health that had previously been missing from the history of health considerations in sport. Recent emphasis on addressing athlete mental health issues marks a necessary and exciting opportunity for the counseling profession; yet, sport psychologists currently dominate this work, despite noted differences in focus. In order to become part of the solution to addressing the mental health needs of athletes at all levels, counselors must prioritize advocacy for athlete mental health and be able to competently describe how their involvement in sport will benefit athletes across the lifespan. A first step for counselors is to better understand the current mental health services that exist for athletes.

The majority of individualized attention to psychologically related services offered to athletes (both collegiate and professional) has historically been provided by practitioners of sport psychology. Two primary organizations exist within the sport psychology profession: the Association for Applied Sport Psychology (AASP) and American Psychological Association (APA) Division 47. AASP certifies master’s-level “consultants” who display competence in kinesiology and psychology to educate athletes on the role of psychological factors in sport performance and teach mental skills that athletes can utilize within and beyond the context of their sport (AASP, 2017). In contrast, APA refers to sport psychology as a specialization within the general practice of psychology for doctoral-level psychologists (APA, 2017). Clinical sport psychologists with proficiency through Division 47 provide clinical interventions for eating disorders, substance use, grief, depression, sexual identity issues, aggression, career transitions, and more (APA, 2017). Practical, organizational, and philosophical differences between these two primary organizations have challenged the sport counseling specialty to establish a unique identity (Aoyagi, Portenga, Poczwardowski, Cohen, & Statler, 2012). Both AASP and Division 47 identify performance optimization as a primary responsibility of sport psychologists, though licensed psychologists with the Division 47 sport psychology proficiency claim specialized knowledge in clinical and counseling issues with athletes and biobehavioral bases of sport and exercise. As a result, athletes seeking mental health services are likely to receive services from sport psychologists with disparate levels of education, varying degrees of competence, and significant differences in their goals for treatment.

This lack of potential continuity of services, coupled with the unique contributions of counseling in sport, marks an opportunity for counselors to become a major resource among athletes. Counselors can address the current discrepancy in services by approaching athlete mental health concerns from a bottom-up, rather than top-down, approach. Counselors can utilize their strength-based, wellness-oriented philosophy to prioritize mental health needs over performance in efforts to enhance performance through improving overall wellness, rather than the reverse. Specialty training in sport can create a more streamlined set of competencies and standards that fall within the general counseling guidelines, but still cater to the unique needs of athletes. Acknowledging the limitations of sport counseling’s history and its current status may encourage clarification of an identity, development of competencies and standards, and recognition of the important contributions that counseling can bring to the culture of athletics.


Sport Counseling: Past and Present

The idea of a sport counseling specialty is hardly new. In 1985, the Counselors of Tomorrow Interest Network of the Association for Counselor Education and Supervision (ACES) described a number of potential counseling specializations for exploration in their publication, Imagine: A Visionary Model for the Counselors of Tomorrow (Nejedlo, Arredondo, & Benjamin, 1985). This publication included a brief section that defined “athletic counseling” and listed associated skills (e.g., counseling, goal setting) and knowledge bases (e.g., NCAA regulations, group facilitation) necessary for practice (Nejedlo et al., 1985). Researchers and educators have since heralded the document as the foundation for defining sport counseling and the treatment of athletes. However, the purpose of this publication was not to establish fundamental principles and standards, but to outline trends, future work environments, and specialty roles in a number of different areas of counseling (Arredondo & Lewis, 2001). The authors did not intend for this list of knowledge bases and skills to serve as a rigorously developed set of competencies for counseling athletes. The intent was to provide a primer for future considerations in sport counseling. The Imagine publication does promote an apparent commitment to a wellness orientation with athletes; however, it serves as the first brick in a foundation for counselors to stand upon, not a jumping-off point for pedagogy and practice.

Hinkle (1989a, 1989b) continued to push for an established sport counseling specialty in papers presented at the Southeastern Psychological Association and Southern ACES. Hinkle also established the ACES Sports Counseling Interest Network in 1992, and the first meeting of the group was held at the American Counseling Association conference in Baltimore (J. S. Hinkle, personal communication, November 13, 2017). In two separate publications, Hinkle (1994) and Petitpas, Buntrock, Van Raalte, and Brewer (1995) made similar arguments that sport counselors must focus on the developmental and emotional aspects of the individual rather than performance optimization and mental skills training. Hinkle (1994) continued by discussing integrated treatment for athletes that included sport psychology, counseling, and developmental and educational programming, highlighting the unique contribution of each profession and the importance of taking a team approach to fully address the diverse needs of athletes. In addition, Hinkle discussed how sport counselors may work with clinical issues, career and life planning, programs for children, and a research agenda.

Though little formal evidence exists, several hurdles have impacted forward progress in the sport counseling arena. For example, there is anecdotal evidence that counselors may view athletes as a population unworthy of services. When asked why G. M. Miller and Wooten’s (1995) sport counseling proposal to the Council for Accreditation of Counseling and Related Educational Programs (CACREP) was never adopted, H. R. Wooten shared, “It appeared that working with athletes was a little ‘boutique’ for most counselors as athletes continued to be seen as privileged” (personal communication, May 27, 2014). Poor visibility among other health professionals working in sport, few opportunities for supervised internships due to a lack of licensed professionals working in sport, limited counseling research with athlete populations, and minimal commitment to athlete mental health until recent years all may have had an effect on the pace at which sport counseling has advanced. Despite counseling researchers’ and advocates’ efforts to move sport counseling forward, more than 20 years later, counselors remain committed to the descriptors of the Imagine publication, but need clarity in professional identity and service provision.

At present, counselors who desire specialized knowledge in working with athletes may be confused by the way that the specialty is being defined and marketed. For example, athletic counseling, is a term used to market academic programs that prepare students for AASP certification and employment in applied sport psychology. Graduates of these programs are not counselors; rather, they meet criteria necessary to be recognized as a Certified Consultant of the Association for Applied Sport Psychology (CC-AASP). A CC-AASP is recognized as an individual trained to enhance athletic performance through mental skills training (AASP, 2017), but it is not a credential that prepares individuals to provide counseling to athletes. A CC-AASP does not participate in many of the typical responsibilities of counselors, including the diagnosis of mental health disorders, substance abuse counseling, and marital or family counseling (AASP, 2017). Counseling certificate programs also utilize the athletic counseling moniker to market their specialized curriculum to licensed counselors, suggesting these programs see a benefit in providing additional training in athletics to individuals already trained as counselors. This model recognizes that the foundational knowledge and skills essential to licensed counselors are important regardless of population or setting. Thus, specialized training related to working in athletics in addition to the core training of licensed counselors may be the best way to maintain cohesion within the counseling profession while still providing athletes with the specialized services they need. Unfortunately, confusion among athletes, coaches, administrators, and other professionals exists because there is a lack of significant knowledge of sport and mental health, which may be the result of a lack of a clear model within the mental health professions about what sport counseling should look like and the distinctive role sports counselors can have when working with athletes. We believe that a commitment to establishing a clearer sport counseling identity would distinguish sport counseling programs like those at Springfield College, California University of Pennsylvania, and Adler University from other programs and would provide enhanced opportunities for graduates wanting to work in athletics.


Implications and Future Directions for Sport Counseling Researchers and Practitioners

Counselors must consider the question: “If the need for sport counselors exists, why haven’t they proliferated among sport organizations?” This question is not easily answered without significant inquiry; still, there is evidence that begins to tell the story. Certainly, the ubiquity of a stigma against mental health in athletics has historically inspired hesitation to seek help (Brewer, Van Raalte, Petitpas, Bachman, & Weinhold, 1998). In fact, counselors are no strangers to this stigma. Historically, individuals have hesitated to seek assistance for mental health concerns due to the societal stigma mental health carries. Over the years, education and awareness efforts have decreased mental health stigma; however, the profession of counseling has continued to struggle with identifying itself as a profession distinct from other mental health professions (Remley & Herlihy, 2016). To mitigate this struggle, counselors have worked tirelessly to educate and advocate for the professional identity of counselors. In doing so, counselors have utilized Nugent’s (1980) guidelines for identifying a mature profession to gain professional distinction (Remley & Herlihy, 2016). These guidelines include having a clearly defined role and scope of practice, offering unique services, having specialized knowledge and skills, having a code of ethics, obtaining legal rights to offer services through licensure and certification, and having an ability to monitor professional practice (Nugent, 1980). In order to achieve these criteria, some members of the profession promote viewing counseling as the predominant profession with specialty areas that continue to support the primary profession (Remley & Herlihy, 2016). As one of the potential specialties, the area of sport counseling can learn from the progress the primary profession of counseling has accomplished. Utilizing the parallels present in the journey of the counseling profession as an example, sport counseling also can develop a mature identity within the counseling profession. Despite this area’s history and obstacles to proliferation, there are many ways that counselors can play an active role in building the sport counseling specialty.

Counselors interested in working with athletes must focus on the development of a comprehensively developed identity. Sport counseling lacks dedicated documentation of the behaviors that practitioners perform. The values and beliefs that distinguish sport counseling from related professions need to be identified. At minimum, the development of competencies, teaching and practice guidelines, and ethical codes are necessary to establish an identity that is separate but compatible with existing services for athletes, while still remaining true to the overall counseling profession. As advocates of a sport counseling specialization begin to take concrete steps toward promoting professional identity, practitioners may be better able to market themselves to stakeholders and find opportunities to begin meeting the mental health needs of athletes.

The 20/20 Vision for the Future of Counseling (20/20; Kaplan & Gladding, 2011) marks an important step in the establishment of a clear and succinct philosophy representative of all counselors. The 20/20 research team used Delphi methodology, an approach to structuring and organizing experts to come to consensus on an area of incomplete knowledge (Powell, 2003), to invite leaders in counseling to determine an updated, more appropriate definition to clarify the profession’s identity (Kaplan & Gladding, 2011). In an effort to unify as one counseling profession, counselors advocating for a distinct sport counseling specialty must consider 20/20 as an opportunity to enhance its professional identity. The development of a disparate or duplicated area would result in further fragmentation. Ultimately, the authors believe that a sport counseling specialty would be best defined by starting with our already existing 20/20 philosophy: “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan, Tarvydas, & Gladding, 2014, p. 366). Further, 20/20 may serve as an important launching pad from which sport counseling advocates can begin to stake out their domain.

A first step in the establishment of the sport counseling specialty is the rigorous development of competencies that are germane to the practice of working with athletes. Competencies, knowledge, skills, and attributes that represent professional qualifications necessary for effective practice may help sport counselors understand and communicate their identity. A lack of an empirically derived set of sport counseling competencies limits sport counselors’ ability to establish their identity and expertise. Researchers should consider the use of Delphi methodology to determine knowledge, skills, and attributes necessary to treat athlete mental health needs at the highest level. Delphi has been performed effectively to outline guidelines for competence in other areas of counselor education (Wester & Borders, 2014), providing evidence for its potential effectiveness in establishing sport counseling competencies. Future considerations for sport counseling competencies may include understanding the demands of the athletic experience, privacy concerns associated with athletic settings, the role of physiology in sport, the influence of competitive environments on mental health, sport culture, the importance of building relationships with athletes and associated individuals (e.g., coaches, athletic trainers, administrators), and additional athlete-specific issues. Researchers might consider querying counselors in practice with athletes, instructors teaching sport counseling courses in counselor education programs, clinical and applied sport psychologists, athletes, and other relevant parties in sport to establish specific areas of competence necessary for sport counselors.

Leaders in sport counseling must also revisit and revise G. M. Miller and Wooten’s (1995) proposed teaching guidelines published in the Journal of Counseling & Development in 1995. G. M. Miller and Wooten cited Nejedlo et al.’s (1985) aforementioned publication and the Association for the Advancement of Applied Sport Psychology (now AASP) as foundational influences on curriculum development. The curriculum was meant to be integrated with the common core and clinical experiences required by CACREP to provide training standards necessary for practice in sport counseling. The 1995 teaching guidelines were ultimately published, but a plan for their adoption was never established. G. M. Miller and Wooten’s publication serves as an important step toward the integration of sport counseling and counselor education that needs to be addressed more fully. A foundation of researched and well-reasoned competencies will eventually give way to curricular guidelines to anchor and clarify sport counseling identity, practice, and ethics.

The adoption of a new code of ethics may not be necessary; however, there are special circumstances for counselors to consider when working with athletes and sports organizations. For example, ethical standards related to confidentiality and relationships with other professionals can apply to working with athletes, coaches, and other athletic staff; however, more explicit statements related to exceptions to confidentiality and how to work effectively on behalf of the athlete while still respecting a referral from a coach may be helpful for counselors working in athletic settings. Sport counselors may find it prudent to learn from sport psychologists, who typically navigate similar work environments. According to sport psychologists Etzel and Watson (2007), several ethical challenges exist that may present themselves on a daily basis.

One primary ethical challenge that sport counselors may face is determining who their client is when working with individual athletes on a professional or university team. Athletic departments responsible for paying for mental health services, as well as coaches and support staff, may assume that they should be made aware of an athlete’s mental health status. Etzel and Watson (2007) pointed out that athletes are perceived by their managers as controlled investments; there is an expectation of being informed and in control. Ethical guidelines must be made clear for sport counselors to negotiate such challenging situations. Additional challenges include navigating multiple roles (e.g., counselor, team consultant, advisor to coaches), impromptu consultations that occur outside of the counseling session, NCAA and professional rules and regulations, and the likely possibility that other parties will notice an athlete seeking the professional’s services if housed in a university or team setting, among countless other potential dual relationships. The establishment of competencies, training guidelines, and ethical standards that apply specifically to counselor–athlete and counselor–team relationships may appear to be a daunting task. Counselors and counselor educators interested in sport must collaborate and advocate for a strongly anchored position in athletics by committing to the development of these foundational elements of sport counseling practice.

Counselors must acknowledge existing and potential outlets for collaboration if sport counseling is to evolve. The ACES Sports Counseling Interest Network, started by Hinkle in 1992, provides a space for counselors interested in discussing present challenges and supports to the growth of sport counseling. Utilization of this medium for collaboration on future research and presentations is vital to the health and expansion of this specialty. Counselors must consider the importance of offering psychoeducational workshops, connecting athletes to mentorship, and developing other organizational supports for athletes in need. These efforts will help to rightly justify counselors’ push for professional inclusion in sporting contexts. An early step will be to normalize the existence of sport counselors among other professionals advocating for improvements to athlete mental health. Counselor membership on the NCAA Mental Health Task Force is a necessary step to becoming a more widely known and respected entity. As sport counselors become more mainstream and accepted professionals in sport, licensed counselors could provide opportunities to counselors-in-training who require supervised internships before starting their careers as sport counselors. Without active networks for collaboration, counselors remain isolated and perhaps less likely to catalyze change.

Developing these professional relationships is critical to gaining entry and contributing to change in sport. Collaborations with organizations committed to athlete health could encourage other like-minded organizations to consider the expertise of counselors. For example, the Institute to Promote Athlete Health and Wellness (IPAHW) at the University of North Carolina at Greensboro, in collaboration with Prevention Strategies, LLC, is an organization committed to the improvement of athlete health and wellness through behavioral intervention programs, policy making, evidence-based training, and intervention evaluation. IPAHW has collaborated with the NCAA Sport Science Institute to ensure that student athletes have access to “myPlaybook: The Freshman Experience,” a catalog of web-based trainings that facilitate behavior change in student athletes across topics like: social norms related to alcohol and drug use, bystander intervention, mental health, time management, hazing, sleep wellness, and sport nutrition (IPAHW, 2017; J. J. Milroy, personal communication, October 3, 2017). Additionally, IPAHW and the NCAA Sport Science Institute are rolling out a new sexual violence prevention course in response to the NCAA’s new policy that requires coaches, student athletes, and administrators to receive sexual violence prevention education (NCAA, 2017a). Counselors have significant training and expertise that may enhance the work of these organizations advocating for health promotion among athlete populations.

Sport counselors must aim to publish athlete mental health research and seek grant funding for experimental research to further establish this specialty. Though relatively new itself, sport psychology has established several journals that address both performance-oriented (e.g., Journal of Applied Sport Psychology) and clinical (e.g., Journal of Clinical Sport Psychology) issues in sport that have yet to be fully explored by counseling researchers. A solidly established sport counselor identity may lead to the eventuality of a sport counseling journal; however, there is a current lack of leadership committed to this task. As the foundational elements detailed above are established to move sport counseling forward, a journal will become a necessity for researchers to expand their knowledge of athlete mental health needs and counselor interventions. Sport counseling researchers publishing in counseling and related journals may need to consider opportunities to fund experimental pilots and larger scale projects. Opportunities for grant funding in sport, although few, are available and range in size and scope. The National Institutes of Health has committed significant funding to the diagnosis of chronic traumatic encephalopathy, a progressive, degenerative brain disease diagnosed at a high rate among deceased athletes of the NFL (Diagnose CTE, 2017). The Center for Healthy African American Men through Partnerships (2017) has expressed interest in funding research on head trauma in athletes. The NCAA annually supports researchers with pilot funding for alcohol abuse intervention and innovative projects designed to enhance student athlete well-being (NCAA, 2017b). Counseling researchers have not procured funding through these opportunities.



More than ever, Myers, Sweeney, and White’s (2002) assertions that counselors must establish their professional identity, enhance their public image, and develop strong interprofessional, collaborative networks remain both relevant and necessary. Counselors currently attempting to break into the safeguarded culture of athletics may struggle to establish credibility and communicate a unified identity. Currently, counselors in sport have a small foundation to stand upon when discussing the specialization of their services to athletes and athletic staffs. The gaps to be filled are clearly labeled and ready to be addressed. The future of sport counseling requires bolstering the literature that outlines its professional development. Counselors involved in sport need to develop relevant research initiatives, obtain funding, and pilot experimental studies that show evidence of improved mental health outcomes with athletes. The marketability of a sport counselor relies on the ability to demonstrate effectiveness with athletes and collaborate with the professional fields that currently saturate sporting contexts. The prospect of a thriving sport counseling specialty is within the counseling profession’s reach. Counselors must now cultivate a sport counseling identity that clearly projects their viability, marketability, and potential for positively influencing athlete mental health.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.



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Stephen P. Hebard, NCC, is an assistant professor at the University of Alabama at Birmingham. Katie A. Lamberson is an assistant professor at the University of North Georgia. Correspondence concerning this article should be addressed to Stephen Hebard, Department of Human Studies, The University of Alabama at Birmingham, 1720 2nd Ave S., EB 207, Birmingham, AL 35294-1250,


An Exploration of Career Counselors’ Perspectives on Advocacy

Melissa J. Fickling

Advocacy with and on behalf of clients is a major way in which counselors fulfill their core professional value of promoting social justice. Career counselors have a unique vantage point regarding social justice due to the economic and social nature of work and can offer useful insights. Q methodology is a mixed methodology that was used to capture the perspectives of 19 career counselors regarding the relative importance of advocacy interventions. A two-factor solution was reached that accounted for 60% of the variance in perspectives on advocacy behaviors. One factor, labeled focus on clients, emphasized the importance of empowering individual clients and teaching self-advocacy. Another factor, labeled focus on multiple roles, highlighted the variety of skills and interventions career counselors use in their work. Interview data revealed that participants desired additional conversations and counselor training concerning advocacy.

Keywords: social justice, advocacy, career counselors, Q methodology, counselor training


The terms advocacy and social justice often are used without clear distinction. Advocacy is the active component of a social justice paradigm. It is a direct intervention or action and is the primary expression of social justice work (Fickling & Gonzalez, 2016; Ratts, Lewis, & Toporek, 2010; Toporek, Lewis, & Crethar, 2009). Despite the fact that counselors have more tools than ever to help them develop advocacy and social justice competence, such as the ACA Advocacy Competencies (Lewis, Arnold, House, & Toporek, 2002) and the Multicultural and Social Justice Counseling Competencies (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015), little is known about practitioners’ perspectives on the use of advocacy interventions.

One life domain in which social inequity can be vividly observed is that of work. The economic recession that began in 2007 has had a lasting impact on the labor market in the United States. Long-term unemployment is still worse than before the recession (Bureau of Labor Statistics, U.S. Department of Labor, 2016a). Further, in the United States, racial bias appears to impact workers and job seekers, as evidenced in part by the fact that the unemployment rate for Black workers is consistently about double that of White workers (e.g., 4.1% White unemployment and 8.2% Black unemployment as of May 2016; Bureau of Labor Statistics, U.S. Department of Labor, 2016b). Recent meta-analyses indicate that unemployment has a direct and causal negative impact on mental health, leading to greater rates of depression and suicide (Milner, Page, & LaMontagne, 2013; Paul & Moser, 2009). Clearly, the worker role is one that carries significant meaning and consequences for people who work or want to work (Blustein, 2006).

The rate at which the work world continues to change has led some to argue that worker adaptability is a key 21st century skill (Niles, Amundson, & Neault, 2010; Savickas, 1997), but encouraging clients to adapt to unjust conditions without also acknowledging the role of unequal social structures is inconsistent with a social justice paradigm (Stead & Perry, 2012). Career counselors, particularly those who work with the long-term unemployed and underemployed, witness the economic and psychological impact of unfair social arrangements on individuals, families and communities. In turn, they have a unique vantage point when it comes to social justice and a significant platform from which to advocate (Chope, 2010; Herr & Niles, 1998; Pope, Briddick, & Wilson, 2013; Pope & Pangelinan, 2010; Prilleltensky & Stead, 2012).

It appears that although career counselors value social justice and are aware of the effects of injustice on clients’ lives, they are acting primarily at the individual rather than the systemic level (Cook, Heppner, & O’Brien, 2005; McMahon, Arthur, & Collins, 2008b; Prilleltensky & Stead, 2012; Sampson, Dozier, & Colvin, 2011). Some research has emerged that focuses on practitioners’ use of advocacy in counseling practice (Arthur, Collins, Marshall, & McMahon, 2013; Arthur, Collins, McMahon, & Marshall, 2009; McMahon et al., 2008b; Singh, Urbano, Haston, & McMahan, 2010). Overall, this research indicates that advocacy is challenging and multifaceted and is viewed as a central component of good counseling work; however, more research is needed if we are to fully understand how valuing social justice translates to use of advocacy interventions in career counseling practice. This study aims to fill this theory–practice gap by illuminating the perceptions of advocacy behaviors from career counselors as they reflect upon their own counseling work.



Through the use of Q methodology, insight into the decisions, motivations and thought processes of participants can be obtained by capturing their subjective points of view. When considering whether to undertake a Q study, Watts and Stenner (2012) encouraged researchers to consider whether revealing what a population thinks about an issue really matters and can make a real difference. Given the ongoing inequality in the labor market, increased attention and energy around matters of social justice in the counseling profession, the lack of knowledge regarding practitioners’ points of view on advocacy, and career counselors’ proximity to social and economic concerns of clients, the answer for the present study is most certainly yes.

Q methodology is fundamentally different from other quantitative research methodologies in the social sciences. It uses both quantitative and qualitative data to construct narratives of distinct perspectives. The term Q was coined to distinguish this methodology from R; Q measures correlations between persons, whereas R measures trait correlations (Brown, 1980). Rather than subjecting a sample of research participants to a collection of measures as in R methodology, Q methodology subjects a sample of items (i.e., the Q sample) to measurement by a collection of individuals through a ranking procedure known as the Q sort (see Figure 1; Watts & Stenner, 2012). Individuals are the variables in Q methodology, and factor analysis is used to reduce the number of points of view into a smaller number of shared perspectives. Then interviews are conducted to allow participants to provide additional data regarding their rankings of the Q sample items. In this study, career counselors were asked to sort a set of advocacy behaviors according to how important they were to their everyday practice of career counseling. Importance to practice was used as the measure of psychological significance since career counselors’ perspectives on advocacy interventions were of interest, rather than self-reported frequency or competence, for example.


Q Sample

The Q sample can be considered the instrumentation in Q methodology. The Q sample is a subset of statements drawn from the concourse of communication, which is defined as the entire population of statements about any given topic (McKeown & Thomas, 2013). The goal when creating the Q sample is to provide a comprehensive but manageable representation of the concourse from which it is taken. For this study, the concourse was that of counselor advocacy behaviors.

The Q sampling approach used for this study was indirect, naturalistic and structured-inductive. Researchers should draw their Q sample from a population of 100 to 300 statements (Webler, Danielson, & Tuler, 2009). For this study, I compiled a list of 180 counselor social justice and advocacy behaviors from a variety of sources including the ACA Advocacy Competencies (Lewis et al., 2002), the Social Justice Advocacy Scale (SJAS; Dean, 2009), the National Career Development Association (NCDA) Minimum Competencies (2009), the Council for Accreditation of Counseling and Related Educational Programs (CACREP) Standards (2009), and key articles in counseling scholarly and trade publications.

Consistent with a structured-inductive sampling strategy, these 180 statements were analyzed to identify categories representing different kinds of advocacy behaviors. By removing duplicates and those items that were more aligned with awareness, knowledge or skill rather than behavior, I was able to narrow the list from 180 to 43 statements. These statements were sorted into five domains that were aligned with the four scales of the SJAS (Dean, 2009) and a fifth added domain. The final domains were: Client Empowerment, Collaborative Action, Community Advocacy, Social/Political Advocacy, and Advocacy with Other Professionals. Aligning the Q sample with existing domains was appropriate since advocacy had been previously operationalized in the counseling literature.

Expert reviewers were used to check for researcher bias in the construction of the Q sample, including the addition of the fifth advocacy domain. Three expert reviewers who were faculty members and published on the topic of social justice in career counseling were asked to review the potential Q sample for breadth, coverage, omissions, clarity of phrasing and the appropriateness of the five domains of advocacy. Two agreed to participate and offered their feedback via a Qualtrics survey, leading to a refined Q sample of 25 counselor advocacy behaviors (see Table 1). Five statements were retained in each of the five domains. Finally, the Q sample and Q sorting procedure were piloted with two career counselors, leading to changes in instructions but not in the Q sample itself. Pilot data were not used in the final analysis.



In Q methodology, participant sampling should be theoretical and include the intentional selection of participants who are likely to have an opinion about the topic of interest (McKeown & Thomas, 2013; Watts & Stenner, 2012). It also is important to invite participants who represent a range of viewpoints and who are demographically diverse. For the current study, the following criteria were required for participant inclusion: (a) holds a master’s degree or higher in counseling and (b) has worked as a career counselor for at least one year full-time in the past two years. For this study, career counselor was defined as having career- or work-related issues as the primary focus of counseling in at least half of the counselor’s case load. Regarding the number of participants in a Q study, emphasis is placed on having enough participants to establish the existence of particular viewpoints, not simply having a large sample since generalizability is not a goal of Q methodology (Brown, 1980). In Q methodology, it also is important to have fewer participants than Q sample items (Watts & Stenner, 2012; Webler et al., 2009).

Participants were recruited by theoretical sampling of my professional network of practitioners, and one participant was recruited through snowball sampling. Nineteen career counselors participated in the present study from six states in the Southeast, West and Midwest regions of the United States. The participant sample was 68% female (n = 13) and 32% male (n = 6); the sample was 84% White and included two Black participants and one multi-racial participant. One participant was an immigrant to the United States and was a non-native English speaker. The participant sample was 95% heterosexual with one participant identifying as gay. Sixty-three percent of participants worked in four-year institutions of higher education and one worked in a community college. Thirty-two percent (n = 6) provided career counseling in non-profit agencies. The average age was 43 (SD = 12) and the average number of years of post-master’s counseling experience was eight (SD = 7); ages ranged from 28 to 66, and years of post-master’s experience ranged from one and a half to 31 years.


Q Sorting Procedure

The Q sort is a method of data collection in which participants rank the Q sample statements according to a condition of instruction along a forced quasi-normal distribution (see Figure 1). There is no time limit to the sorting task and participants are able to move the statements around the distribution until they are satisfied with their final configuration. The function of the forced distribution is to encourage active decision making and comparison of the Q sample items to one another (Brown, 1980).


Figure 1

Sample Q Sort Distribution

The condition of instruction for this study was, “Sort the following counselor advocacy behaviors according to how important or unimportant they are to your career counseling work.” The two poles of the distribution were most important and most unimportant. Poles range from most to most so that the ends of the distribution represent the areas that hold the greatest degree of psychological significance to the participant, and the middle of the distribution represents items that hold relatively little meaning or are more neutral in importance (Watts & Stenner, 2012).

The Q sorts for this study were conducted both in person and via phone or video chat (i.e., Google Hangouts, Skype). Once informed consent was obtained, I facilitated the Q sorting procedure by reading the condition of instruction, observing the sorting process, and conducting the post-sort interview. Once each participant felt satisfied with his or her sort, the distribution of statements was recorded onto a response sheet for later data entry.


Post-Sort Interview

Immediately following the Q sort, I conducted a semistructured interview with each participant in order to gain a greater understanding of the meaning of the items and their placement, as well as his or her broader understanding of the topic at hand (Watts & Stenner, 2012). The information gathered during the interview is used when interpreting the final emergent factors. Items in the middle of the distribution are not neglected and are specifically asked about during the post-sort interview so that the researcher can gain an understanding of the entire Q sort for each participant. Although the interview data are crucial to a complete and rigorous factor interpretation and should be conducted with every participant in every Q study, the data analysis process is guided by the quantitative criteria for factor analysis and factor extraction. The qualitative interview data, as well as the demographic data, are meant to help the researcher better understand the results of the quantitative analysis.


Data Analysis

Data were entered into the PQMethod program (Schmolck, 2014) and Pearson product moment correlations were calculated for each set of Q sorts. Inspection of the correlation matrix revealed that all sorts (i.e., all participants) were positively correlated with one another, some of them significantly so. This indicated a high degree of consensus among the participants regarding the role of advocacy in career counseling, which was further explored through factor analysis.

I used centroid factor analysis and Watts and Stenner’s (2012) recommendation of beginning by extracting one factor for every six Q sorts. Centroid factor analysis is the method of choice among Q methodologists because it allows for a fuller exploration of the data than a principal components analysis (McKeown & Thomas, 2013; Watts & Stenner, 2012). Next, I calculated the significance level at p < .01, which was .516 for this 25-item Q sample.

The unrotated factor matrix revealed two factors with Eigenvalues near or above the commonly accepted cutoff of 1 according to the Kaiser-Guttman rule (Kaiser, 1970). Brown (1978) argued that although Eigenvalues often indicate factor strength or importance, they should not solely guide factor extraction in Q methodology since “the significance of Q factors is not defined objectively (i.e., statistically), but theoretically in terms of the social-psychological situation to which the emergent factors are functionally related” (p. 118). Since there currently is little empirical evidence of differing perspectives on advocacy among career counselors, two factors were retained for rotation.

In order to gain another perspective on the data, I used the Varimax procedure. I flagged those sorts that loaded significantly (i.e., at or above 0.516) onto only one factor after rotation. Four participants (2, 8, 9 and 17) loaded significantly onto both rotated factors and were therefore dropped from the study and excluded from further analysis (Brown, 1980; Watts & Stenner, 2012). Two rotated factors were retained, which accounted for 60% of the variance in perspectives on advocacy behaviors. Fifteen of the original 19 participants were retained in this factor solution.

Q methodology uses only orthogonal rotation techniques, meaning that all factors are zero-correlated. Even so, it is possible for factors to be significantly correlated but still justify retaining separate factors (Watts & Stenner, 2012). The two factors in this study are correlated at 0.71. This correlation indicates that the perspectives expressed by the two factor arrays share a point of view but are still distinguishable and worthy of exploration as long as the general degree of consensus is kept in mind (Watts & Stenner, 2012).


Constructing Factor Arrays

After the two rotated factors were identified, factor arrays were constructed in PQMethod. A factor array is a composite Q sort and the best possible estimate of the factor’s viewpoint using the 25 Q sample items. First, a factor weight was calculated for each of the 15 Q sorts that loaded onto a factor. Next, normalized factor scores (z scores) were calculated for each statement on each factor, which were finally converted into factor arrays (see Table 1). In Q methodology, unlike traditional factor analysis, attention is focused more on factor scores than factor loadings. Since factor scores are based on weighted averages, Q sorts with higher factor loadings contribute proportionally more to the final factor score for each item in a factor than those with relatively low factor loadings. Finally, factors were named by examining the distinguishing statements and interview data of participants that loaded onto the respective factors. Factor one was labeled focus on clients and factor two was labeled focus on multiple roles.


Factor Characteristics

Factor one was labeled focus on clients and accounted for 32% of the variance in perspectives on advocacy behaviors. It included nine participants. The demographic breakdown on this factor was: six females, three males; eight White individuals and one person who identified as multi-racial. The average age on this factor was about 51 (SD = 10.33), ranging from 37 to 66. Persons on this factor had on average 11 years of post-master’s counseling experience (SD = 8.6), ranging from one and a half to 31 years. Fifty-six percent of participants on this factor worked in 4-year colleges or universities, 33% in non-profit agencies, and one person worked at a community college.

Factor two was labeled focus on multiple roles and accounted for 28% of the variance in career counselors’ perspectives on advocacy behaviors. It included six participants. Five participants on this factor identified as female and one identified as male. Five persons were White; one was Black. The average age of participants on this factor was almost 35 (SD = 6.79), ranging from 29 to 48, and they had an average of just over seven years of post-master’s experience (SD = 3.76), ranging from three and a half to 14 years. Four worked in higher education, and two worked in non-profit settings.


Factor Interpretation

In the factor interpretation phase of data analysis, the researcher constructs a narrative for each factor by incorporating post-sort interview data with the factor arrays to communicate the rich point of view of each factor (Watts & Stenner, 2012). Each participant’s interview was considered only in conjunction with the other participants on the factor on which they loaded. I read post-sort interview transcripts, looking for shared perspectives and meaning, in order to understand each factor array and enrich each factor beyond the statements of the Q sample. Thus, the results are reported below in narrative form, incorporating direct quotes and paraphrased summaries from interview data, but structured around the corresponding factor arrays.

Table 1

Q Sample Statements, Factor Scores and Q Sort Values



Factor 1

Factor 2

Factor Score


Factor Score


1 Question intervention practices that appear inappropriate.





2 Seek feedback regarding others’ perceptions of my advocacy efforts.





3 Serve as a mediator between clients and institutions.





4 Express views on proposed bills that will impact clients.





5 Maintain open dialogue to ensure that advocacy efforts are consistent with group goals.





6 Encourage clients to research the laws and policies that apply to them.





7 Collect data to show the need for change in institutions.





8 Educate other professionals about the unique needs of my clients.





9 Help clients develop needed skills.





10 Assist clients in carrying out action plans.





11 Help clients overcome internalized negative stereotypes.





12 Conduct assessments that are inclusive of community members’ perspectives.





13 With allies, prepare convincing rationales for social change.





14 Identify strengths and resources of clients.





15 Get out of the office to educate people about how and where to get help.





16 Teach colleagues to recognize sources of bias within institutions and agencies.





17 Deal with resistance to change at the community/system level.





18 Collaborate with other professionals who are involved in disseminating public information.





19 Help clients identify the external barriers that affect their development.





20 Use multiple sources of intervention, such as individual counseling, social advocacy and case management.





21 Train other counselors to develop multicultural knowledge and skills.





22 Work to ensure that clients have access to the resources necessary to meet their needs.





23 Work to change legislation and policy that negatively affects clients.





24 Ask other counselors to think about what social change is.





25 Communicate with my legislators regarding social issues that impact my clients.





Note. Q sort values are -4 to 4 to correspond with the Q distribution (Figure 1) where 4 is most important
and -4 is most unimportant; QSV = Q Sort Value.




Factor 1: Focus on Clients

For participants on the focus on clients factor, the most important advocacy behavior was to “identify client strengths and resources” (see Table 1). When speaking about this item, participants often discussed teaching clients self-advocacy skills, stating that this is a key way in which career counselors promote social justice. Identifying client strengths and resources was referred to as “the starting point,” “the bottom line” and even the very “definition of career counseling.” One participant said that counseling is about “empowering our clients or jobseekers, whatever we call them, to do advocacy on their own behalf and to tell their story.” In general, persons on this factor were most concerned with empowering individual clients; for example, “I would say, even when we’re doing group counseling and family counseling, ultimately it’s about helping the person in the one-to-one.” Similarly, one participant said, “Instead of fighting for the group in legislation or out in the community, I’m working with each individual to help them better advocate for themselves.” Interview data indicated that social justice was a strongly held value for persons on this factor, but they typically emphasized the need for balancing their views on social injustice with their clients’ objectives; they wanted to take care not to prioritize their own agendas over those of their clients.

Several participants on this factor perceived items related to legislation or policy change as among the least client-centered behaviors and therefore as the more unimportant advocacy behaviors in their career counseling work. Persons on this factor stated that advocacy at the systems level was neither a strength of theirs nor a preference. A few reported that there are other people in their offices or campuses whose job is to focus on policy or legislative change. There also was a level of skepticism about counselors’ power to influence social change. In regard to influencing legislative change in support of clients, one participant said, “I don’t think in my lifetime that is going to happen. Maybe someday it will. I’m just thinking about market change right now instead of legislative change.”

Interview data revealed that career counselors on this factor thought about advocacy in terms of leadership, both positively and negatively. One person felt that a lack of leadership was a barrier to career counselors doing more advocacy work. Another person indicated that leaders were the ones who publicly called for social change and that this was neither his personality nor approach to making change, preferring instead to act at the micro level. Finally, persons on this factor expressed that conversations about social change or social justice were seen as potentially divisive in their work settings. One White participant said the following:

There is a reluctance to do social justice work because—and it’s mostly White people—people really don’t understand what it means, or feel like they don’t have a right to do that, or feel like they might be overstepping. Talking about race or anything else, people are really nervous and they don’t want to offend or say something that might be wrong, so as a result they just don’t engage on that level or on that topic.


Factor 2: Focus on Multiple Roles

One distinguishing feature of the focus on multiple roles factor was the relatively high importance placed on using multiple sources of intervention (see Table 1). Participants described this as being all-encompassing of what a career counselor does and reflective of the multiple roles a career counselor may hold. One participant said, “You never know what the client is going to come in with,” arguing that career counselors have to be open to multiple sources of intervention by necessity. Another participant indicated that she wished she could rely more on multiple sources of intervention but that the specialized nature of her office constricted her ability to do so.

Participants on this factor cited a lack of awareness or skills as a barrier to their implementing more advocacy behaviors. They were quick to identify social justice as a natural concern of career counselors and one that career counselors are well qualified to address due to their ability to remain aware of personal, mental health and career-related concerns simultaneously. One participant said:

I don’t know if the profession of career counseling is really seen as being as great as it is in that most of us have counseling backgrounds and can really tackle the issues of career on a number of different levels.

In talking about the nature of career counseling, another participant said, “Social justice impacts work in so many ways. It would make sense for those external barriers to come into our conversations.”

Regarding collaborating with other professionals to prepare convincing rationales for social change, one participant stated that there are already enough rationales for social change; therefore, this advocacy behavior was seen as less important to her. Persons on this factor placed relatively higher importance on valuing feedback on advocacy efforts than did participants on factor one. One participant said she would like to seek feedback more often but had not thought of doing so in a while: “I did this more when I was in graduate school because you are thinking about your thinking all the time. As a practitioner, as long as social justice and advocacy are on my radar, that’s good.”



Neither setting nor gender appeared to differentiate the factors, but age and years of post-master’s experience may have been distinguishing variables. Younger individuals and those with fewer years of post-master’s experience tended to load onto factor two. Factor one had an average age of 51 compared to 35 for factor two, and the average age for all study participants was 43. It is interesting to note that the four participants who loaded onto both factors and were therefore dropped from analysis had an average of just over two years of post-master’s counseling experience versus 11 for factor one and seven for factor two. It is possible that their more recent training regarding advocacy may account for some differences in perspective from those of more experienced counselors.

Participants on factor one (focus on clients) who emphasized the importance of individual clients tended to perceive it as more difficult to have conversations about social justice with their peers or supervisors. In contrast, participants on factor two (focus on multiple roles) were more likely to cite a lack of knowledge or skills regarding their reasons for not engaging in more advocacy behaviors beyond the client level. Factor arrays indicated that factor one participants viewed engaging at the community level as more important, whereas participants on factor two viewed conversations with colleagues and clients about social justice as more important to their work.

The broader view of persons on factor two regarding the career counselor’s role and their openness to acknowledging their own lack of awareness or skills may reflect a different kind of socialization around advocacy compared to persons on factor one. Career counselors who graduated from counseling programs prior to the emphasis on multicultural competence in the early 1990s or before the inclusion of social justice in the literature and CACREP standards in the first decade of the 21st century may have had limited exposure to thinking about contextual or social factors that impact client wellness. Persons on both factors, however, expressed interest in social justice and felt that the vast majority of advocacy behaviors were important.

In post-sort interviews, participants from both factors described a gradual shift in emphasis from a focus on the individual on the right hand (most important) side of the Q sort distribution to an emphasis on legislation on the left hand (most unimportant) side. For example, the statement identify strengths and resources of clients was one of the most important behaviors for nearly every participant. Likewise, the statement work to change legislation and policy that negatively affects clients was ranked among the most unimportant advocacy behaviors for both factors. Interestingly, the statement encourage clients to research the laws and policies that apply to them was a consensus statement with a Q sort value of 0, or the very middle of the distribution. Since this advocacy behavior is both client focused and presumably would provide clients with important self-advocacy skills, it is interesting that it was ranked lower than other items related to client self-advocacy. Some participants indicated that they considered this item a “passive” counselor behavior in that they might encourage clients to research laws but could not or would not follow up with clients on this task. One participant said she would like to encourage clients to research laws that apply to them but shared that she would first need to learn more about the laws that impact her clients in order to feel effective in using this intervention.

Participants were asked directly about potential barriers to advocacy and potential strengths of career counselors in promoting social justice. Responses are discussed below. The questions about strengths and barriers in the post-sort interview did not reference Q sample items, so participant responses are reported together below.


Barriers to Promoting Social Justice

In the post-sort interviews, lack of time was mentioned by nearly every participant as a barrier to implementing more advocacy in career counseling, and it often came in the form of little institutional support for engaging in advocacy. For example, participants indicated that while their supervisors would not stop them from doing advocacy work, they would not provide material support (e.g., time off, reduced case load) to do so. This finding is consistent with other literature that suggests that career counselors report a lack of institutional support for engaging in advocacy (Arthur et al., 2009).

Another major barrier to advocacy was a lack of skill or confidence in one’s ability as an advocate. Advocacy at the social/political level requires a unique set of skills (M. A. Lee, Smith, & Henry, 2013), which practitioners in the present study may or may not have learned during their counseling training. Pieterse, Evans, Risner-Butner, Collins, and Mason (2009) reviewed 54 syllabi from required multicultural courses in American Psychological Association (APA)- and CACREP-accredited programs and found that awareness and knowledge tended to be emphasized more than skill building or application of social justice advocacy. This seems to have been reflected in the responses from many participants in the present study.

Participants on both factors indicated that they held some negative associations to advocacy work, calling it “flag waving” or “yelling and screaming” about inequality or social issues. They expressed some concern about how they might be perceived by their peers if they were to engage in advocacy; however, involvement in this study seemed to provide participants with a new understanding of advocacy as something that happens at the individual as well as at the social level. Participants appeared to finish the data collection sessions with a more positive understanding of what advocacy is and could be.


Strengths of Career Counselors in Promoting Social Justice

In addition to discussing barriers to advocacy, participants were asked directly about strengths of career counselors in promoting social justice and were able to identify many. First and foremost, participants saw the ability to develop one-on-one relationships with clients as a strength. One participant nicely captured the essence of all responses in this area by stating, “The key thing is our work one-on-one with an individual to say that even though you’re in a bad place, you have strengths, you have resources, and you have value.” Participants indicated that social change happens through a process of empowering clients, instilling hope and seeing diversity as a strength of a client’s career identity. The ability to develop strong counseling relationships was attributed partially to participants’ counseling training and identity, as well as to their exposure to a broad range of client concerns due to the inseparable nature of work from all other aspects of clients’ lives (Herr & Niles, 1998; Tang, 2003).

Career counselors in this study served diverse populations and highly valued doing so. These participants described multicultural counseling skills and experience as central to competent career counseling and to advocacy. They felt that they possessed and valued multicultural competence, which bodes well for their potential to engage in competent and ethical advocacy work with additional training, experience and supervision (Crook, Stenger, & Gesselman, 2015; Vespia, Fitzpatrick, Fouad, Kantamneni, & Chen, 2010).

Finally, participants felt that career counseling is seen as more accessible than mental health counseling to some clients, giving career counselors unique insight into clients’ social and personal worlds. Participants reported having a broad perspective on their clients’ lives and therefore unique opportunities to advocate for social justice. Relatedly, participants noted that the more concrete and tangible nature of career counseling and its outcomes (e.g., employment) may lead policymakers to be interested in hearing career counselors’ perspectives on social issues related to work. One participant noted that “there’s a huge conversation to be had around work and social justice” and that career counselors’ key strength “is empowering clients and the broader community to understand the role of work.”


Implications for Career Counselors, Counselor Educators, and Supervisors

Nearly all participants described the sorting process as thought provoking and indicated that social justice and advocacy were topics they appreciated the opportunity to think more about. There was a strong desire among some practitioners in this study to talk more openly with colleagues about social justice and its connection to career counseling, but a lingering hesitation as well. Therefore, one implication of the present study is that practitioners should begin to engage in discussions about this topic with colleagues and leaders in the profession. If there is a shared value for advocacy beyond the individual level, but time and skills are perceived as barriers, perhaps a larger conversation about the role of career counselors is timely. Career counselors may benefit from finding like-minded colleagues with whom to talk about social justice and advocacy. Support from peers may help practitioners strategize ways to question or challenge coworkers who may be practicing career counseling in ways that hinder social justice.

To move toward greater self-awareness and ethical advocacy, practitioners and career counseling leaders must ask themselves critical and self-reflexive questions about their roles and contributions in promoting social justice (McIlveen & Patton, 2006; Prilleltensky & Stead, 2012). Some authors have indicated there is an inherent tension in considering a social justice perspective and that starting such conversations can even lead to more questions than answers (Prilleltensky & Stead, 2012; Stead & Perry, 2012). Counselors should turn their communication skills and tolerance for ambiguity inward and toward one another in order to invite open and honest conversations about their role in promoting social justice for clients and communities. The participants in this study seem eager to do so, though leadership may be required to get the process started in a constructive and meaningful way.

Counselor educators and supervisors can provide counselors-in-training increased experience with systemic-level advocacy by integrating the ACA Advocacy Competencies and the Multicultural and Social Justice Counseling Competencies into all core coursework. Even though broaching issues of social justice has been reported as challenging and potentially risky, counselor educators should integrate such frameworks and competencies in active and experiential ways (Kiselica & Robinson, 2001; M. A. Lee et al., 2013; Lopez-Baez & Paylo, 2009; Manis, 2012). Singh and colleagues (2010) found that even self-identified social justice advocates struggled at times with initiating difficult conversations with colleagues; they argued that programs should do more to help counselors-in-training develop skills “to anticipate and address the inevitable interpersonal challenges inherent in advocacy work” (p. 141). Skills in leadership, teamwork and providing constructive feedback might be beneficial to prepare future counselors for addressing injustice. Furthermore, Crook and colleagues (2015) found that advocacy training via coursework or workshops is associated with higher levels of perceived advocacy competence among school counselors, lending more support in favor of multi-level training opportunities.



The current study is one initial step in a much-needed body of research regarding advocacy practice in career counseling. It did not measure actual counselor engagement in advocacy, which is important to fully understand the current state of advocacy practice; rather, it measured perceived relative importance of advocacy behaviors. Researcher subjectivity may be considered a limitation of this study, as researcher decisions influenced the construction of the Q sample, the factor analysis and the interpretation of the emergent factors. By integrating feedback from two expert reviewers during construction of the Q sample, I minimized the potential for bias at the design stage. Factor interpretation is open to the researcher’s unique lens and also may be considered a limitation, but if it is done well, interpretation in Q methodology should be constrained by the factor array and interview data. Although generalizability is not a goal of Q methodology, the sample size in this study is small and therefore limits the scope of the findings.


Suggestions for Future Research and Conclusion

Advocacy is central to career counseling’s relevance in the 21st century (Arthur et al., 2009; Blustein, McWhirter, & Perry, 2005; McMahon, Arthur, & Collins, 2008a), yet due to the complexity and personal nature of this work, more research is required if we are to engage in advocacy competently, ethically and effectively. There appears to be interest among career counselors in gaining additional skills and knowledge regarding advocacy, so future research could include analyzing the effects of a training curriculum on perceptions of and engagement with advocacy. Outcome research could also be beneficial to understand whether career counselors who engage in high levels of advocacy report different client outcomes than those who do not. Finally, research with directors of career counseling departments could be helpful to understand what, if any, changes to career counselors’ roles are possible if career counselors are interested in doing more advocacy work. Understanding the perspectives of these leaders could help further the conversation regarding the ideals of social justice and the reality of expectations and demands faced by career counseling offices and agencies.

This research study is among the first to capture U.S. career counselors’ perspectives on a range of advocacy behaviors rather than attitudes about social justice in general. It adds empirical support to the notion that additional conversations and training around advocacy are wanted and needed among practicing career counselors. Stead (2013) wrote that knowledge becomes accepted through discourse; it is hoped that the knowledge this study produces will add to the social justice discourse in career counseling and move the profession toward a more integrated understanding of how career counselors view the advocate role and how they can work toward making social justice a reality.



Conflict of Interest and Funding Disclosure

The author conducted this research with the assistance of grants awarded by the National Career Development Association, the North Carolina Career Development Association, and the Southern Association for Counselor Education and Supervision.



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Melissa J. Fickling, NCC, is an Assistant Professor at the University of Memphis. Correspondence can be addressed to Melissa J. Fickling, University of Memphis, Ball Hall 100, Memphis, TN 38152,