Mar 30, 2018 | Volume 8 - Issue 1
April D. Johnston, Aida Midgett, Diana M. Doumas, Steve Moody
This mixed methods study assessed the appropriateness of an “aged-up,” brief bullying bystander intervention (STAC) and explored the lived experiences of high school students trained in the program. Quantitative results included an increase in knowledge and confidence to intervene in bullying situations, awareness of bullying, and use of the STAC strategies. Utilizing the consensual qualitative research methodology, we found students spoke about (a) increased awareness of bullying situations, leading to a heightened sense of responsibility to act; (b) a sense of empowerment to take action, resulting in positive feelings; (c) fears related to intervening in bullying situations; and (d) the natural fit of the intervention strategies. Implications for counselors include the role of the school counselor in program implementation and training school staff to support student “defenders,” as well as how counselors in other settings can work with clients to learn the STAC strategies through psychoeducation and skills practice.
Keywords: bullying, bystander intervention, consensual qualitative research (CQR), high school, mixed methods
Researchers have defined bullying as “when one or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again” (Centers for Disease Control & Prevention [CDCP], 2017, p. 7). Bullying includes verbal, physical, or relational aggression, as it often occurs through the use of technology (e.g., cyberbullying). National statistics indicate approximately 20.5% of high school students are victims of bullying at school and 15.8% are victims of cyberbullying (CDCP, National Center for Injury Prevention and Control, 2016). Although school bullying peaks in middle school, it remains a significant problem at the high school level, with the highest rates of cyberbullying reported by high school seniors (18.7%; U.S. Department of Education, National Center for Education Statistics, 2016).
There are wide-ranging negative consequences experienced by students who are exposed to bullying as either a target or bystander (Bauman, Toomey, & Walker, 2013; Doumas, Midgett, & Johnston, 2017; Hertz, Everett Jones, Barrios, David-Ferdon, & Holt, 2015; Rivers & Noret, 2013; Rivers, Poteat, Noret, & Ashurst, 2009; Smalley, Warren, & Barefoot, 2017). High school students who are targets of bullying report higher levels of risky health behaviors, including physical inactivity, less sleep, risky sexual practices (Hertz et al., 2015), elevated substance use (Doumas et al., 2017; Smalley et al., 2017), and higher levels of depression and suicidal ideation (Bauman et al., 2013; Smalley et al., 2017). Adolescents who observe bullying as bystanders also report associated negative consequences, and, in some instances, report more problems than students who are directly involved in bullying situations (Rivers & Noret, 2013; Rivers et al., 2009). Specifically, bystanders have been found to be at higher risk for substance abuse and overall mental health concerns than students who are targets (Rivers et al., 2009). Bystanders also are significantly more likely to report symptoms of helplessness and potential suicidal ideation compared to students not involved in bullying (Rivers & Noret, 2013). Furthermore, although bystanders are often successful when they intervene on behalf of targets of bullying (Gage, Prykanowski, & Larson, 2014), bystanders usually do not intervene because they do not know what to do (Forsberg, Thornberg, & Samuelsson, 2014; Hutchinson, 2012). Failure to respond to observed bullying leads to feelings of guilt (Hutchinson, 2012) and coping through moral disengagement (Forsberg et al., 2014). Thus, there is a need to train bystanders to intervene to both reduce bullying and buffer bystanders from the negative consequences associated with observing bullying without acting.
To address the negative effects that can result from being exposed to bullying, researchers have developed numerous bullying prevention and intervention programs for implementation within the school setting. Many of these programs are comprehensive, school-wide interventions (Polanin, Espelage, & Pigott, 2012; Ttofi, Farrington, Lösel, & Loeber, 2011). However, findings indicate these programs are most effective for students in middle and elementary school (Yeager, Fong, Lee, & Espelage, 2015). Additionally, a recent meta-analysis indicates that bystander intervention is an important component of bullying intervention; however, few comprehensive programs include a bystander component (Polanin et al., 2012). Further, those programs that do include a bystander component have been normed on children within the context of the classroom setting (Salmivalli, 2010). High school students experience greater independence at school, with less adult supervision in the hallways and at lunch, and move to different classroom locations throughout the day. Thus, there is a need for effective bullying bystander programs and interventions that have been “aged up” specifically for the high school level (Denny et al., 2015).
The STAC Program
The STAC program is a brief bystander intervention that teaches students who witness bullying to intervene as “defenders” (Midgett, Doumas, Sears, Lundquist, & Hausheer, 2015). The STAC acronym stands for the four bullying intervention strategies taught in the program: “Stealing the Show,” “Turning It Over,” “Accompanying Others,” and “Coaching Compassion.” The second author created the STAC program for the middle and elementary school level with the intention of establishing school counselors as leaders in program implementation. The program includes a 90-minute training with bi-weekly, 15-minute small group follow-up meetings, placing low demands on schools for implementation. Findings from studies conducted at the elementary and middle school level indicate students trained in the STAC program report an increase in knowledge and confidence to intervene as defenders (Midgett et al., 2015; Midgett & Doumas, 2016; Midgett, Doumas, & Trull, 2017), as well as increased use of the STAC strategies (Midgett, Doumas, Trull, & Johnston, 2017). Additionally, research demonstrates students trained in the STAC program report reductions in bullying (Midgett, Doumas, Trull, & Johnson, 2017), as well as increases in self-esteem (Midgett, Doumas, & Trull, 2017) and decreases in anxiety (Midgett, Doumas, Trull, & Johnston, 2017), compared to students in a control group.
Development of the STAC Program for High School
The authors conducted a previous qualitative study to inform the modification of the original STAC program to be appropriate for the high school level (for details, see Midgett, Doumas, Johnston, et al., 2017). Based upon data generated from high school students, the authors “aged up” the STAC program by incorporating the following content into the didactic and role-play components of the training: (a) cyberbullying through social media and texting, (b) group dynamics in bullying, and (c) bullying in dating and romantic relationships. The authors also aged up the program by including developmentally appropriate language (e.g., breaks vs. recess) and content, including common locations where bullying occurs (e.g., school parking lot vs. the school bus) and age-appropriate examples of physical bullying (e.g., covert behaviors such as “shoulder checking,” “backpack checking,” and “tripping” vs. physical fights).
Purpose of the Study
The purpose of this study was to extend the literature by evaluating the appropriateness of the aged-up STAC program for the high school level and to explore the experiences of students trained in the program. Following guidelines suggested by Leech and Onwuegbuzie (2010), the literature review guided the formulation of the study rationale, goal, objectives, and research questions. Despite the need to provide anti-bullying programs to high school students, the majority of bullying intervention research has been conducted with elementary and middle school students (Denny et al., 2015). Although intervening on behalf of students who are targets of bullying is associated with positive outcomes (Hawkins, Pepler, & Craig, 2001), research on bystander intervention programs aged up for high school students is limited. The present authors could find only one program, StandUP, developed specifically for high school students. Results of a pilot study indicated students participating in the 3-session StandUP online program reported an increase in positive bystander behavior and decreases in bullying behavior (Timmons-Mitchell, Levesque, Harris, Flannery, & Falcone, 2016). The research noted several methodological limitations that limit the generalizability and validity of the findings, including a 6.8% response rate, 22% attrition rate with differential attrition by race and bullying status, and the use of a single-group design.
Thus, the goal of this study was to add to the knowledge on bullying interventions for high school students. Our objectives were to (a) examine the influence of the STAC program on knowledge and confidence, awareness of bullying, and use of the STAC strategies, and (b) describe and explore the experience of high school students participating in the STAC intervention. We were interested in answering the following mixed method research questions: (a) Do students trained in the aged-up STAC intervention report an increase in knowledge and confidence to intervene as defenders? (b) Do students trained in the aged-up STAC intervention have an increased awareness of bullying? (c) Do students trained in the aged-up STAC intervention use the STAC strategies to intervene when they observe bullying? and (d) What were high school students’ experiences of participating in the aged-up STAC intervention and using the STAC strategies to intervene in bullying situations?
Mixed Research Design
A mixed methods design was implemented with a single group of participants who completed the STAC training. We were interested in the influence of the STAC intervention on students’ knowledge and confidence, awareness of bullying, and use of the STAC strategies. An additional interest was to understand students’ experiences of the STAC training. The purpose of selecting a mixed methods design was to maximize interpretation of findings, as mixed methods designs often result in a greater understanding of complex phenomena than either quantitative or qualitative studies can produce alone (Creswell, 2013). Hesse-Biber (2010) also advocates for the convergence of qualitative and quantitative data to enhance and triangulate findings. Following the guidelines described by Leech and Onwuegbuzie (2010), we chose to supplement the quantitative data with qualitative data to investigate the in-depth, lived experiences of high school students trained as defenders in the aged-up STAC program. Our research design was a partially mixed, sequential design (Creswell, 2009; Leech & Onwuegbuzie, 2010). The quantitative design was a single-group repeated-measures design and the qualitative component included consensual qualitative research (CQR; Hill et al., 2005).
Our sampling design was sequential-identical (Leech & Onwuegbuzie, 2010), with the same participants completing surveys followed by focus groups. The sample consisted of 22 students
(n = 15 females [68.2%]; n = 7 males [31.8%]) recruited from a public high school via stratified random sampling in the Northwestern region of the United States. Participants ranged in age from 15–18 years old (M = 16.82 and SD = 0.91), with reported racial backgrounds of 59.1% White, 18.2% Asian, 13.6% Hispanic, and 9.1% African American. Of the 22 participants trained in the STAC program, 100% participated in follow-up focus groups and follow-up data collection.
The current study was completed as part of a larger study designed to develop and test the effectiveness of the aged-up STAC intervention. Following institutional research board approval, the researchers randomly selected 200 students using stratified proportionate sampling and then obtained parental consent and student assent from 57 students, for a response rate of 28.5%. The current sample consists of the 22 students who participated in the STAC intervention. The recruiting team included school counselors, a doctoral student, and master’s students. A team member met briefly with students selected to discuss the project and provided an informed consent form to be signed by a parent or guardian. A team member met with students with parental consent to explain the research in greater detail and to obtain student assent. Researchers trained participants in the 90-minute aged-up STAC program and then conducted two 15-minute bi-weekly follow-up meetings for 30 days following the training. Students completed baseline, post-training, and 30-day follow-up surveys. Six weeks after the STAC training, team members conducted three 45-minute open-ended, semi-structured focus groups to investigate students’ experiences being trained as defenders in the aged-up STAC program. Researchers audio recorded the focus groups for transcription purposes. The team provided pizza to students after the follow-up survey and at the end of each focus group. The university and school district review boards approved all research procedures.
Knowledge and Confidence to Intervene. The Student-Advocates Pre- and Post-Scale (SAPPS; Midgett et al., 2015) was used to measure knowledge of bullying, knowledge of the STAC strategies, and confidence to intervene. The questionnaire is comprised of 11 items that measure student knowledge of bullying behaviors, knowledge of the STAC strategies, and confidence intervening in bullying situations. Examples of items include: “I know what verbal bullying looks like,” “I know how to use humor to get attention away from the student being bullied,” and “I feel confident in my ability to do something helpful to decrease bullying at my school.” Items are rated on a 4-point Likert scale ranging from 1 (I totally disagree) to 4 (I totally agree). Items are summed to create a total scale score. The SAPPS has established content validity and adequate internal consistency with Cronbach’s alpha ranging from .75–.81 (Midgett et al., 2015; Midgett & Doumas, 2016; Midgett, Doumas, & Trull, 2017; Midgett, Doumas, Trull, & Johnston, 2017). Cronbach’s alpha was .83 for this sample.
Awareness of Bullying. Awareness of bullying was assessed using one item. Students were asked to respond Yes or No to the following question: “Have you seen bullying at school in the past month?” Prior research has used this question to test the impact of the STAC program on observing and identifying bullying behavior post-training (Midgett, Doumas, Trull, & Johnston, 2017).
Use of STAC Strategies. The use of each STAC strategy was measured by a single item. Students were asked, “How often would you say that you used these strategies to stop bullying in the past month? (a) Stealing the Show—using humor to get the attention away from the bullying situation,
(b) Turning It Over—telling an adult about what you saw, (c) Accompanying Others—reaching out to the student who was the target of bullying, and (d) Coaching Compassion—helping the student who bullied develop empathy for the target.” Items were rated on a 5-point Likert scale ranging from 1 (Never/Almost Never) to 5 (Always/Almost Always). Prior research has used these items to examine use of STAC strategies post-training (Midgett, Doumas, Trull, & Johnston, 2017).
High School Students’ Experiences. Researchers followed Hill et al.’s (2005) recommendation to develop a semi-structured interview protocol to answer the question, “What were high school students’ experiences of participating in the aged-up STAC intervention and using the STAC strategies to intervene in bullying situations?” Researchers developed questions based on previous qualitative findings with middle school students (Midgett, Moody, Reilly, & Lyter, 2017), quantitative results indicating students trained in the program use the STAC strategies (Midgett, Moody, et al., 2017), and a review of the literature (Jacob & Furgerson, 2012). Researchers asked students the following questions: (1) Can you please talk about the personal values you had before the STAC training that were in line with what you learned during the STAC training? (2) Please share your experience using the STAC strategies (Stealing the Show, Turning It Over, Accompanying Others, and Coaching Compassion), (3) Can you share how using the STAC strategies made you feel about yourself? (4) How did being trained in the STAC program impact your relationships? (5) Can you please talk about your fears related to using the strategies in different bullying situations? and, (6) Overall, what was it like to be trained in the STAC program and use the STAC strategies?
The STAC Intervention
The STAC intervention began with a 90-minute training, which included information about bullying and strategies for intervening in bullying situations (Midgett et al., 2015). Following the training, facilitators met with students twice for 15 minutes throughout the subsequent 30 days to support them as they applied what they learned in the training. During these meetings, researchers reviewed the STAC strategies with students, and asked students about bullying situations they witnessed and whether they utilized a strategy. If students indicated they observed bullying but did not utilize a strategy, researchers helped students brainstorm ways in which they could utilize one of the four STAC strategies in the future.
Didactic Component. The didactic component included icebreaker exercises, an audiovisual presentation, two videos about bullying, and hands-on activities to engage students in the learning process. Students learned about (a) the complex nature of bullying in high school often involving group dynamics rather than single individuals; (b) different types of bullying, with a focus on cyberbullying and covert physical bullying; (c) characteristics of students who bully, including the likelihood they have been bullied themselves, to foster empathy and separate the behavior from the student; (d) negative associated consequences of bullying for students who are targets, perpetrate bullying, and are bystanders; (e) bystander roles and the importance of acting as a defender; and (f) the STAC strategies used for intervening in bullying situations. The four strategies are described below.
Stealing the Show. Stealing the Show involves using humor or distraction to turn students’ attention away from the bullying situation. Trainers teach bystanders to interrupt a bullying situation to displace the peer audience’s attention away from the target (e.g., tell a joke, initiate a conversation with the student who is being bullied, or invite peers to play a group game such as basketball).
Turning It Over. Turning It Over involves informing an adult about the situation and asking for help. During the training, students identify safe adults at school who can help. Students are taught to always “turn it over” if there is physical bullying taking place or if they are unsure as to how to intervene. Trainers also emphasized the importance of documenting evidence in cyberbullying cases by taking a screenshot or picture of the computer or cell phone over time for authorities (i.e., school principal and resource officer) to take action.
Accompanying Others. Accompanying Others involves the bystander reaching out to the student who was targeted to communicate that what happened is not acceptable, that the student who was targeted is not alone, and that the student bystander cares about them. Trainers provide examples of how students can use this strategy either directly, by inviting a student who was targeted to talk about the situation, or indirectly, by approaching a peer after they were targeted and inviting them to go to lunch or spend time with the bystander. This strategy focuses on communicating empathy and support to the student who was targeted.
Coaching Compassion. Coaching Compassion involves gently confronting the student who bullied either during or after the bullying incident to communicate that his or her behavior is unacceptable. Additionally, the student bystander encourages the student who bullied to consider what it would feel like to be the target in the situation, thereby fostering empathy toward the target. Bystanders are encouraged to implement Coaching Compassion when they have a relationship with the student who bullied or if the student who bullied is in a lower grade and the bystander believes they will respect them.
Role-Plays. Trainers divided students into small groups to practice the STAC strategies through role-plays that included hypothetical bullying situations. The team developed the scenarios based on student feedback on types of bullying that occur in high school, including cyberbullying, romantic relationship issues, and covert physical bullying (Midgett, Doumas, Johnston, Trull, & Miller, 2017). See Appendix A for the STAC scenarios.
Post-Training Groups. STAC training participants met in 15-minute groups with two graduate student trainers twice in the 30 days post-training. In these meetings, students reviewed the STAC strategies, shared which strategies they used, and explained whether they felt the strategies were effective in intervening in bullying. Trainers also addressed questions and supported students in brainstorming other ways to implement the strategies, including combining strategies or working as a group to intervene together.
Quantitative. The authors used quantitative analyses to test for significant changes in knowledge and confidence and to provide descriptive statistics for frequency of awareness of bullying and the use of the STAC strategies. An a priori power analysis was conducted using the G*Power 3.1.3 program (Faul, Erdfelder, Lang, & Buchner, 2007) for a repeated-measures, within-subjects ANOVA with three time points. Results of the power analysis indicated a sample size of 20 was needed for power of > 0.80 to detect a medium effect size for the main effect of time with an alpha level of .05. Thus, the final sample size of 22 met the needed size to provide adequate power for analyses.
Before conducting primary analyses, all variables were examined for outliers and normality. The authors found no outliers and all variables were within the normal range for skew and kurtosis. To assess changes in knowledge and confidence, we conducted a GLM repeated-measures ANOVA with one independent variable, time (baseline, post-intervention, follow-up), and post-hoc follow-up paired t-tests to examine differences between time points. To evaluate awareness of bullying, we computed descriptive statistics to determine how many participants observed bullying at baseline and follow-up. To evaluate the use of STAC strategies, we computed descriptive statistics to examine the frequency of use of each strategy at the follow-up assessment. The authors used an alpha level of p < .05 to determine statistical significance and used partial eta squared (h2p) as the measure of effect size for the repeated-measures ANOVA and Cohen’s d for paired t-test with magnitude of effects interpreted as follows: small (h2p > .01; d = .20), medium (h2p > .06; d = .50), and large (h2p > .14; d = .80; Cohen, 1969; Richardson, 2011). All analyses were conducted using SPSS version 24.0.
Qualitative. The authors conducted focus groups and employed CQR methodology to investigate participant experiences (Hill et al., 2005). Specifically, CQR was chosen because it uses elements from phenomenology, grounded theory, and comprehensive process (Hill et al., 2005). CQR is predominantly constructivist with postmodern influence (Hill et al., 2005), which was a good fit for the project as we were interested in students’ experiences being trained in the aged-up STAC program. Furthermore, we selected CQR because it includes semi-structured interviews to promote the exploration of participants’ experiences, while also allowing for spontaneous probes that can uncover related experiences and insights, adding depth to findings (Hill et al., 2005). CQR was well suited for this study because it requires a team of researchers working together to reach consensus analyzing complex data (Hill et al., 2005). Focus groups were chosen because they allow researchers to observe participants’ interactions and shared experiences such as teasing, joking, and anecdotes that can add depth to the findings (Kitzinger, 1995). Focus groups have potential therapeutic benefits for participants, including increasing feelings of self-worth (Powell & Single, 1996) and empowerment (Race, Hotch, & Parker, 1994). Additionally, focus groups can be especially useful when power differentials exist between participants and decision makers (Morgan & Kreuger, 1993).
Three team members (the first and second authors and a master’s in counseling student) employed the CQR methodology to analyze the data. After the data transcription, each member worked individually to identify domains and core ideas prior to meeting as a group. The team met three times in the next month to achieve consensus. Researchers relied on participant quotations to resolve disagreements, to cross-analyze the data, and to move into more abstract levels of analysis (Hill et al., 2005). The team labeled domains as general (typical of all but one participant or all participants), typical (more than half of participants), and variant (at least two participants; Hill et al., 2005). An external auditor analyzed the data separately, utilizing NVivo qualitative analysis software (Version 10; 2012), and reported similar findings with the exception of a minor modification to one domain, which the team incorporated into final findings. Next, the researchers conducted member checks (Lincoln & Guba, 1985) by emailing all participants with an overview of the findings. All participants who responded agreed the findings were an accurate representation of their experience.
Strategies for Trustworthiness. As recommended by Hays, Wood, Dahl, and Kirk-Jenkins (2016), we used multiple strategies to strengthen the trustworthiness of the study. First, our process was reflexive with continuous awareness of expectations and biases. Prior to conducting focus groups, we discussed and wrote memos about our expectations and biases (Creswell, 2013). To triangulate data, all three analysts were involved throughout the process and in comparing findings among the team. An external auditor was included to provide oversight and increase credibility of findings. Once all researchers reached agreement about major findings, we elicited participant feedback to increase credibility and confirmability of our findings (Lincoln & Guba, 1985).
Knowledge and Confidence
The researchers examined changes in knowledge and confidence across three time points (baseline, post-intervention, and follow-up). Results indicated a significant main effect for time: Wilks’ Lambda = .31, F (2, 20) = 6.85, p < .000, h2p = .31. Follow-up paired t-tests indicated a significant difference in knowledge and confidence between baseline (M = 35.68, SD = 4.35) and post-intervention (M = 40.64, SD =3.11), t(21) = -6.52, p < .001, Cohen’s d = -1.46; and between baseline (M = 35.68, SD = 4.35) and 30-day follow-up (M = 40.68, SD = 4.10), t(21) = -4.96, p < .001, Cohen’s d = -1.06; but not between post-intervention (M = 40.64, SD = 3.11) and 30-day follow-up (M = 40.68, SD = 4.10), t(21) = -0.05, p = .96, Cohen’s d = -.01. Findings indicate students reported an increase in knowledge and confidence from baseline to post-intervention, and this increase was sustained at the 30-day follow-up.
Awareness of Bullying
The researchers examined rates of observing bullying at baseline and at the 30-day follow-up to determine if students became more aware of bullying after being trained in the STAC program. Rates of observing bullying increased from 54.5% to 63.6%, indicating that the STAC program raised awareness of bullying.
Use of the STAC Strategies
The researchers examined how frequently students in the intervention group used the STAC strategies at the 30-day follow-up. Among students who reported witnessing bullying (63.6%, n = 14), 100% indicated using one or more STAC strategies in the past month. Specifically, 64.3% reported using Stealing the Show, 42.9% reported using Turning It Over, 100% reported using Accompany Others, and 85.7% reported using Coaching Compassion.
Through CQR analysis, the team agreed on four domains with supporting core ideas. All of the domains below are general or typical and endorsed by participants via member checks.
Domain 1: Awareness and Sense of Responsibility. Participants (n = 8; 57%) talked about the STAC program enhancing their awareness of bullying behavior and increasing their sense of responsibility to act. Students spoke about some types of bullying being difficult to recognize and that the STAC training helped them become more aware of covert bullying situations. One participant gave an example about being able to recognize types of bullying that can often be overlooked. The student shared, “People look like they’re joking around and you . . . ignore it, but now it’s like they’re not [joking]. You can tell a little bit. I think . . . [the STAC program] brought . . . [awareness] out in us.” Students also talked about their experience being able to recognize different types of bullying and being equipped to intervene, as well as becoming aware that their actions can have an impact on others. One participant shared that “learning the different ways you can address . . . [bullying] also helps you realize the different forms it happens in, so it makes you value being aware of what’s going on and how your own actions affect other people.” Another student also spoke about the connection between being trained to act as a defender and a newfound sense of responsibility and shared that after STAC training, “there’s not really a reason to say that you don’t want to [get involved] because you’re scared, because you know what’s happening to the person is wrong and if you can change it, you should.” Another participant stated that “there’s some others that don’t have this training, so we’re the ones that should be stepping in if we see it. Everyone should, but . . . we know what to do.”
Domain 2: Empowerment and Positive Feelings. Participants (n = 9; 64%) spoke about a sense of empowerment and associated positive feelings that came from using the STAC strategies to intervene in bullying situations. For example, one participant stated, “It makes you feel a little bit more empowered because you realize you actually can make a difference in someone else’s life or in the whole community at your school or community in general.” Students also talked about the STAC program empowering them to make decisions about their friendships. A participant shared, “I actually told some people I didn’t want to talk to them or be friends with them [because] I can’t be around someone who is making fun of people with disabilities. . . . So, it changed the way I picked my friends.” Some students talked about the association between a sense of empowerment to make a difference in a bullying situation and feeling good about themselves and helping other students. A student said, “I feel like it made us feel good, like we made a positive difference in some way regarding the person that’s being bullied. So it makes it feel like we did something good, like a good deed.” Another student shared, “Somebody actually went to talk to him [ethnic minority student who was bullied] . . . and that was me. It was good to see him happy after he was feeling sad.”
Domain 3: Fears. Almost all participants (n = 12; 86%) spoke about how acting as a defender elicited fears related to judgment from peers or creating tension with friends. For example, one student shared, “I have a fear of being judged, which is kind of the thing of bullying. So, I try not to be so active with people at school.” Another participant also talked about fears related to peer judgment and creating tension with friends when utilizing the STAC strategy Accompanying Others by having lunch with a student who was a target of bullying. The student said, “It’s a social fear, or like ‘why are you hanging out with them?’ . . . and it’s kind of tense between you and your other friends because you brought this person that they didn’t want.” Students also talked about fears of making a situation worse. In particular, participants spoke about fears about reporting bullying situations to adults by using the STAC strategy Turning It Over. For example, one participant stated, “When you get teachers involved or your parents . . . [bullying] kind of . . . escalates . . . a lot of kids will avoid going to adults if they can until it gets physical.” However, most participants were encouraged to act despite their fears, and many discovered that the STAC program allowed them to overcome their fears. One participant stated, “I think starting out my biggest fear was that [using STAC strategies] wasn’t going to do anything, that nothing was going to change, but it really did, and I was pretty shocked that I had a positive effect on people.”
Domain 4: Natural Fit of STAC Strategies and Being Equipped to Intervene. Many participants (n = 10; 71%) indicated the STAC strategies were a natural fit and equipped them with tools to intervene when they witnessed bullying. For example, one student shared, “Stealing the Show [was a natural fit]. I think it happened during accelerated PE. Someone was making fun of someone’s bench max, and I could tell the person was uncomfortable, so I just made a joke or something and changed the subject.” Another participant spoke about Coaching Compassion: “It’s probably one of my favorite ones because it actually does something in the moment, [and] it actually taught me how I can put out the effort without feeling uncomfortable when doing it.” Further, participants shared that implementing the strategies increased their knowledge and confidence to intervene. For example, one participant shared, “You know when to use them [the strategies] and when it’s not necessary and how far you should go when using them.” The strategies seemed to successfully meet participants at their level of understanding and equip them with more structure and guidance to intervene more confidently and consistently.
The purpose of this study was to investigate the appropriateness of the aged-up STAC program for the high school level and to explore the experiences of high school students trained in the program. Quantitative data indicated students trained in the aged-up program reported an increase in knowledge and confidence to intervene and an increase in awareness of bullying, and also reported using the STAC strategies when they observed bullying at school. Qualitative data enhanced the interpretation of quantitative findings, depicting students’ experiences being trained in the program and using the STAC strategies.
Findings indicate that participating in the STAC training was associated with an increased awareness and sense of responsibility. Reported rates of observing bullying increased from baseline to the 30-day follow-up (54.5% to 63.6%). These findings are consistent with research showing students trained in the STAC program report increased awareness of bullying behavior (Midgett, Doumas, Trull, & Johnston, 2017). Further, students indicated that once they became aware of covert bullying, they felt responsible to intervene. One explanation for this finding is that participating in the training leads to an increase in awareness of bullying situations, which promotes a sense of responsibility to act. This explanation is consistent with research suggesting that awareness of negative consequences to others leads to an increase in feelings of personal responsibility, which in turn, leads to action (de Groot & Steg, 2009).
Our data also revealed that the STAC training was associated with an increase in knowledge and confidence and a sense of empowerment associated with positive feelings and changes in friendships. These findings are consistent with research showing that when students intervene in bullying situations they feel a sense of congruence, a positive sense of self (Midgett, Moody, et al., 2017), and a sense of well-being (Schwartz, Keyl, Marcum, & Bode, 2009). Researchers also have shown that when bystanders do not intervene, the lack of action leads to guilt (Hutchinson, 2012) and moral disengagement (Forsberg et al., 2014). Further, researchers have found that students have a desire to belong to a peer group with similar values in “defending” behaviors as their own (Sijtsema, Rambaran, Caravita, & Gini, 2014). Thus, it is possible that the confidence and positive feelings associated with being trained to act as defenders extended to feeling empowered to disengage from peers who do not intervene on behalf of targets of bullying.
Results indicated students used Turning It Over the least frequently among the strategies, with only 49% of students using this strategy. This finding is in direct contrast to research with middle school students suggesting Turning It Over is used by 91% of students (Midgett, Doumas, Trull, & Johnston, 2017). Qualitative data revealed that students felt fearful about intervening; specifically, students talked about being afraid that Turning It Over to an adult would make the situation worse. This finding parallels research suggesting that high school students believe adults at school do not handle bullying effectively (Midgett, Doumas, Johnston, et al., 2017) and that when they report bullying to teachers, the situation either remains the same or worsens (Fekkes, Pijpers, & Verloove-Vanhorick, 2005). Coupled with research indicating students are more likely to report bullying when they believe their teachers will act (Cortes & Kochenderfer-Ladd, 2014) and will be effective in intervening (Veenstra, Lindenberg, Huitsing, Sainio, & Salmivalli, 2014), our findings suggest it may be useful to provide teachers with knowledge and skills so that they may effectively support students who report bullying.
Finally, findings indicated that 100% of students who witnessed bullying post-training used at least one STAC strategy and that students experienced the STAC strategies as a natural fit and felt equipped with tools to act in bullying situations. These findings are consistent with prior research indicating students trained in the STAC program report using the strategies (Midgett, Moody, et al., 2017; Midgett, Doumas, Trull, & Johnston, 2017). The most frequently used strategies were Accompanying Others and Coaching Compassion, used by 100% and 85.7% of students, respectively. One explanation for these two strategies being the most natural fit for students is that the formation of peer relationships is an important developmental priority for adolescents (Wang & Eccles, 2012). Accompanying Others allows students to foster relationships in a way that feels natural and altruistic. Also, as adolescents mature emotionally and their ability to empathize grows (Allemand, Steiger, & Fend, 2015), Coaching Compassion can encourage bystanders and students who bully to develop empathy toward targets.
Limitations and Future Research
Although this study contributes to the literature regarding developmentally appropriate bullying interventions for high school students, several limitations must be considered. First, because of our small sample size and lack of control group, we cannot make causal attributions or generalize our findings to the larger high school student population. Although we enhanced the significance of our findings with a mixed methods design, there is a need for future studies investigating the efficacy of the aged-up STAC program through a randomized controlled trial. Further, since our study was intended as a first step in the development of an age-appropriate program for high school, we did not assess decreases in bullying victimization or perpetration. Therefore, future randomized controlled trial studies should include these outcome variables. Another limitation is related to the measures used. Specifically, both awareness of bullying and use of each STAC strategy were measured by a single item, which can result in decreased reliability. Further, although the developers constructed the items to have face validity, there are no studies investigating the psychometric properties of these items in measuring awareness of bullying or use of the STAC strategies. Additionally, our quantitative and qualitative findings were based on self-report data. It is possible that students’ responses were influenced by their desire to please the researchers, especially within the context of the focus groups. Thus, including objective measures of observable defending behaviors would strengthen the findings.
Our findings provide important implications for counselors in both school and other settings. First, high school counselors can implement aged-up bullying intervention programs such as the STAC program. High school counselors can find encouragement in our findings indicating high school students are invested in helping reduce school bullying and that being trained to intervene can be associated with increased awareness and sense of responsibility. Further, findings suggest it might be helpful for school counselors to provide students trained in the program with an opportunity to meet in small groups to foster friendships with peers who are committed to acting as defenders.
Results also suggest that high school students believe reporting bullying to adults may not be an effective strategy. School counselors are well positioned as student advocates to establish anonymous reporting procedures to counteract potential student fears related to being negatively perceived when they report bullying to adults. In all bullying intervention efforts, school counselors should coordinate with administration to ensure success. School counselors can facilitate teacher and staff development to help them understand students’ fears related to reporting bullying and provide teachers with necessary tools to help students who report bullying to them. Additionally, although a teacher training would increase the required time and resources needed to implement the STAC program, it may be an important addition at the high school level. In this module, school counselors could educate teachers about bullying and the STAC strategies so that teachers could reinforce the strategies with students. The training would emphasize Turning It Over, explaining to teachers their important role in helping student bystanders intervene when they observe bullying.
Lastly, this study also has implications for counselors working with adolescents outside the school setting. There are negative associated consequences to witnessing bullying as a bystander (Rivers & Noret, 2013; Rivers et al., 2009). In addition, adolescents report not knowing how to intervene on behalf of targets (Forsberg et al., 2014; Hutchinson, 2012), which can lead to feelings of guilt (Hutchinson, 2012). Thus, counselors can empower clients to act as defenders by providing psychoeducation regarding the STAC strategies. They can focus on strategies that clients feel are a natural fit as a starting point. Counselors can encourage clients to share bullying situations they most commonly observe at school and invite clients to talk through how they could use a favorite STAC strategy.
Bullying is a significant problem among high school students. This study provided support for the aged-up STAC intervention as an anti-bullying approach that is appropriate for high school students. Specifically, the STAC program helped students be more aware of bullying, feel a stronger sense of responsibility to intervene, and feel empowered to use the STAC strategies.
Conflict of Interest and Funding Disclosure
The authors received internal funding for this project from a College of Education Seed Grant from Boise State University.
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Aged-Up STAC Scenarios
In the PE locker room, you overhear some girls talking about another girl who is going through a break-up. You hear them call her a “loser” (and some other hurtful names) and gossip about the reasons she and her boyfriend broke up. They also talk about how the girl is not skinny or pretty enough to date the guy.
For a few weeks during break, you have noticed a group of students stand in the middle of the hallway and “shoulder check” another student as he tries to walk by to get to his next class on the other side of the school. Today, the student is tripped by one of the students standing with a group and something he was carrying was damaged.
Your friends are hanging out at your house after school, looking through Twitter. One friend decided to follow a girl from school that they do not like and then repost one of her posts making fun of her in a humiliating way. This is not the first time your friend has done something like this.
You are in the parking lot and suddenly you hear yelling coming from a car that is trying to pull out of a parking spot. You see a guy yelling at his girlfriend that she can’t go to lunch with a certain friend because he saw the text messages they sent last night. You know this happens a lot with this guy, and you’ve been concerned for a while.
April D. Johnston is a doctoral student at Boise State University. Aida Midgett is an associate professor at Boise State University. Diana M. Doumas is a professor at Boise State University. Steve Moody, NCC, is an assistant professor at Idaho State University. Correspondence can be addressed to April Johnston, 1910 University Blvd, Boise, ID 83725, email@example.com.
Jul 20, 2016 | Article, Volume 6 - Issue 2
Marc A. Grimmett, Adria S. Dunbar, Teshanee Williams, Cory Clark, Brittany Prioleau, Jen S. Miller
Research studies indicate that the number of African Americans diagnosed with oppositional defiant disorder (ODD) is disproportionately higher than other demographic groups (Feisthamel & Schwartz, 2009; Schwartz & Feisthamel, 2009). One contributing factor for this disproportionality is that White American clients presenting with the same disruptive behavioral symptoms as African American clients tend to be diagnosed with adjustment disorder. Feisthamel and Schwartz (2009) concluded, “counselors perceive attention deficit, oppositional, and conduct-related problems as significantly more common among clients of color” (p. 51), and racial diagnostic bias may influence the assessment process. Racial biases in clinical decision making are explained in a conceptual pathway developed by Feisthamel and Schwartz (2007).
In the pathway, counselors who hold stereotypical beliefs about clients selectively attend to client information. The counselor’s judgment is influenced by personal bias, resulting in misdiagnosing the client. African American masculinity stereotypes of criminal mindedness, violent behavior, aggression and hostility (Spencer, 2013) held by counselors with low multicultural social justice counseling competence (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015; Sue, Arredondo, & McDavis, 1992) potentially foster misdiagnosis and overdiagnosis of African American males with ODD.
Studies on how African American males are diagnosed with ODD and specific implications for African American males are relatively nonexistent. McNeil, Capage, and Bennett (2002) indicated the majority of information on children diagnosed with ODD has been obtained from primarily White children and families. They recommended that counselors working with African American families consider the African American family’s unique stressors, worldviews and burdens; possible inclusion of the extended family; possible therapist biases that conflict with client’s worldview; and positive factors that lead to competency, self-reliance and health in African American culture (Lindsey & Cuellar, 2000). Thus, an appropriate ODD diagnosis in African American males requires assessment and treatment plan considerations that include other related factors.
Diagnosing Oppositional Defiant Disorder in African American Males
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013), ODD is characterized by a pattern of behavior that includes angry and irritable mood, argumentative and defiant behavior, and/or vindictiveness. Symptoms must cause significant problems at home, school or work; must occur with at least one individual who is not a sibling; and must persist for 6 months or more (APA, 2013). The diagnostic assessment also determines that (a) these behaviors are displayed more often than is typical for peers, and (b) symptoms are not associated with other mental health disorders such as anxiety, depression, antisocial behavior and substance abuse disorders.
High rates of ODD diagnosis among African American males may occur because of low cultural competency in diagnosis and counselor bias (Guindon & Sobhany, 2001; Hays, Prosek, & McLeod, 2010; Snowden, 2003). Spencer and Oatts (1999) and Clark (2007), for example, found that health professionals misinterpreted symptoms of disruptive behavior disorders like ODD at greater rates for African American children. Misdiagnosis was common among children assessed as having symptoms of (a) obsessive compulsive disorder and response to rigid classroom rules, (b) bipolar disorder or attention-deficit/hyperactivity disorder and engagement in destructive behavior, and (c) anxiety disorder (e.g., social anxiety) and dislike for school, and defiance toward teachers. These symptoms also may result from unfair treatment and discrimination (Smith & Harper, 2015). Misdiagnosis of ODD can reasonably be expected to have potentially adverse implications for healthy psychological, emotional and social development in family and education systems.
Primary caregivers of children diagnosed with ODD report mild to moderate levels of depression and anxiety and severe levels of stress (Oruche et al., 2015). Caregivers report having overwhelming difficulty managing the aggressive and defiant nature of their children’s behaviors and constantly watching over their children to prevent them from hurting themselves or others (Oruche et al., 2015). The well-being of family members who are not primary caregivers (i.e., in some cases fathers, siblings, grandparents) is rarely considered in disruptive behavior research, although these family members experience many of the same stressors outlined by primary caregivers (Kilmer, Cook, Taylor, Kane, & Clark, 2008). Siblings of diagnosed adolescents have demonstrated high rates of anxiety, poor school performance and adjustment problems (Kilmer et al., 2008; Oruche et al., 2015). Children with disruptive behavior disorders whose family members participated in their treatment showed improved grade point averages and attendance and reduced drop-out rates relative to students whose family members considered themselves uninvolved (Reinke, Herman, Petras, & Ialongo, 2008). While family interventions appear helpful, an accurate diagnosis remains the first step in creating an effective treatment plan and not causing further harm to clients (e.g., school suspension, expulsion, incarceration; Smith & Harper, 2015).
Students with aggressive disruptive behaviors also have higher rates of mental health risk factors, including school maladjustment, antisocial activity, substance use and early sexual activity (Schofield, Bierman, Heinrichs, & Nix, 2008). Children diagnosed with ODD experience a range of academic problems, including in-school suspensions (Reinke et al., 2008), high school drop-out (Vitaro, Brendgen, Larose, & Trembaly, 2005), and lower academic grades and achievement scores (Bub, McCartney, & Willett, 2007). ODD was not cited as a contributing factor; however, a recent report by Smith and Harper (2015) revealed that in Southern states African American males comprised 47% of student suspensions and 44% of expulsions from K–12 public schools in the United States, which was highest among all racial and ethnic groups. School administrators also were more likely to rate African American children higher on symptoms related to behavioral disorders than White American children (Epstein et al., 2005).
Finally, 50–70% of juveniles detained in the United States have a diagnosable behavioral health disorder (e.g., ODD; Schubert & Mulvey, 2014). While African American youth make up only 16% of the total youth population in the United States, they account for 37% of the detained population (National Council on Crime and Delinquency, 2007). Given the potential negative trajectory of an ODD diagnosis for some African American males, the diagnostic process warrants further consideration.
The purpose of this qualitative research study was to (a) help understand and explain the contextual factors, diagnostic processes and counseling outcomes associated with the diagnosis of ODD in African American males, and (b) identify, describe, and make meaning of patterns and trends in mental health care systems that may be associated with the apparent overdiagnosis of African American boys with ODD. A consensual qualitative research (CQR) design was employed in this study to identify, describe and make meaning of the diagnostic processes and outcomes related to ODD. The following components of CQR identified by Hill et al. (2005) were used in this study: (a) open-ended questions in semistructured interviews “to allow for the collection of consistent data across individuals, as well as more in-depth examination of individual experiences,” (b) research team collaboration (i.e., two judges and one auditor) throughout the data analysis process for multiple perspectives, (c) “consensus to arrive at the meaning of the data,” (d) an auditor to check the work of the two judges; and (e) “domains, core ideas, and cross-analyses in the data analysis” (p. 196).
The research team included a counselor educator and licensed psychologist (African American male, age 42), counselor educator and licensed professional counselor (White American female, age 36), three clinical mental health graduate students (African American female, age 23; White American female, age 28; White American male, age 29) and one public administration graduate student (African American female, 34). All research team members had clinical experience (i.e., as mental health counselors, research and counseling interns, or parents of clients receiving counseling) with African American males who have been diagnosed with ODD. Training to conduct the study involved reading and discussing [Hill, Knox, Thompson, Williams, Hess, & Ladany, 2005; Hill, Thompson, & Williams, 1997]; attending in-person research team meetings to discuss, design, plan and implement the research study; and electronic communication throughout the process. Feelings and reactions (i.e., biases) related to the study were openly discussed among the research team throughout the process to minimize influences on data analysis. Research team biases included: (a) awareness of apparent disproportionality of ODD diagnosis in African American males compared to other populations, based on clinical experience, (b) potential low multicultural competence of counselors making diagnoses, and (c) difficulties for African American males with an ODD diagnosis.
Six mental health professionals met the following criteria for participation in this study: (a) the ability to verbally describe and explain the diagnostic criteria for ODD (during the interview for data collection), (b) a minimum of 2 years’ clinical experience working with clients who have ODD as demonstrated by professional resume or curriculum vitae and explanation at the interview, and (c) a professional mental health license.
The sample consisted of diverse practitioners in identity, years of experience, professional position and places of employment. Racial/ethnic and gender identities of participants were: African American female, African American male, multiracial Arab American female, White American female (n = 2), and White American male. Participant ages ranged from: (a) 30–35 years (n = 2), (b) 35–40 years (n = 2) and (c) over 40 years (n = 2). Reported mental health licenses included: licensed professional counselor associate (n = 1), licensed professional counselor (n = 2), licensed professional counselor supervisor (n = 1), licensed clinical social worker (n = 1) and licensed psychological associate (n = 1). Years holding licensure ranged from less than one to greater than 15. The majority of participants described their professional position as a clinical supervisor and mental health counselor (n = 3), with others identifying as mental health counselors (n = 2) and multisystemic therapy program supervisor (n = 1). All participants reported working within a private organization, with two participants employed by a for-profit community mental health agency, three participants by a non-profit community mental health agency and one participant in private practice.
The Institutional Review Board for the Use of Human Subjects in Research evaluated and approved the study. Participant recruitment involved purposeful sampling of mental health providers from local Critical Access Behavioral Health Agencies likely to meet participant criteria. Research team members contacted 10 potential participants by e-mail and follow-up phone calls to explain the study and ask for their participation. Once eligibility had been determined based on selection criteria, six mental health professionals were selected to create an intentionally diverse sample. Participants scheduled an in-person appointment to complete the informed consent process with a team member, signed the form indicating understanding and agreement to participate in the study, and engaged in an in-depth interview lasting 1 to 1.5 hours, at the office of the participants or the first author. Codes and pseudonyms protected confidential participant information and data was audio-recorded and transcribed for each interview.
Semi-structured interviews. Interview questions for the study were based on a literature review, an evaluation of the DSM-5 (APA, 2013) criteria for ODD, and pilot field interviews with mental health professionals, clients, and clinical directors experienced in providing or receiving services related to ODD. Participants were asked 12 initial questions about the process of making an ODD diagnosis for African American male clients that focused on: life circumstances that contributed to an ODD diagnosis; structural and cultural factors related to diagnosis (e.g., What are the social systems involved in the diagnosis?); post-diagnosis outcomes and implications (e.g., What happens after a client receives the diagnosis?); and treatment plan considerations (e.g., What are the benefits and/or problems of the treatment plan?).
Data were analyzed using CQR beginning with a start domain list created from the initial interview questions and transcript of the first interview, where all research team members coded first interview data into domains, “topics used to group or cluster data” (Hill et al., 2005, p. 200). Next, core ideas, “summaries of the data that capture the essence of what was said in fewer words with greater clarity,” from each domain were recorded using direct quotes from participants (Hill et al., 2005, p. 200). Cross-analysis was then completed to characterize the frequency of the data: “general applies to all or all but one case; typical applies to more than half up to cutoff for general; and variant applies to two cases up to the cutoff for typical” (Hill et al., 2005, p. 203). Finally, one team member acted as the auditor and provided feedback throughout the analysis process, and most importantly, ensured “that all important material has been faithfully represented in the core ideas, that the wording of the core ideas succinctly captures the essence of the raw data, and that the cross-analysis elegantly and faithfully represents the data” (Hill et al., p. 201).
The consensus process commenced in the collaborative team design and implementation of the study and proceeded with the independent analysis of the data by the coders and auditor. Domains, core ideas and cross-analyses were then presented, discussed, debated and confirmed during in-person research team meetings, by e-mail and video conferencing. A multilayered consensus process over time contributed to the stability of the data for trustworthiness, along with: (a) consistency and documentation of data collection procedures, (b) research team description and positionality statement, (c) providing quotes that capture core ideas, and (d) using a research team of coders and an auditor to analyze data. No cases were withheld from the initial cross-analysis for the stability check of the data, as Hill et al. (2005) found it is not necessary. Rather, Hill et al. (2005) suggested presenting “evidence of trustworthiness in conducting data analysis,” as described (p. 202).
Four domains were identified related to diagnosing ODD. Categories further define each domain, supported by core ideas using direct quotes from the participants. Table 1 shows the frequency of categories within each of the domains. Hill et al. (1997) outlined the following categories: general if it applies to all (6), typical if it applies to half or more (3–5), and variant if it applies to less than half of the participants (2 up to typical; all categories applied to at least half of the participants; therefore, none were variant).
Most insurance companies require counselors to diagnose clients with a mental disorder in order to obtain payment for mental health services (Kautz, Mauch, & Smith, 2008). Many insurance companies require that a diagnosis be made during the first few counseling sessions, sometimes within the very first counseling session. All participants described the role and influence of insurance companies and managed care in the diagnostic process. One participant expressed, “the diagnosis is necessary to get paid, so you have to find something. You are not looking objectively. You are just giving them a diagnosis.” The participant continued:
We see this proportion of diagnoses [with African American males] because the insurance in managed care world drives agencies like this one and drives providers to say that an [African American] child is diagnosed a particular way . . . There is this incentive to diagnose and to diagnose in a short period of time.
|Table 1Summary of Domains From the Cross-Analysis of the Participants (N = 6)
Domain and Category
|Diagnosis required for payment of services
|Reimbursement likelihood drives the type of diagnosis given
|Insufficient assessment time allotted for proper diagnosis
|Oppositional defiant disorder diagnostic criteria
|Criteria are too general
|Criteria provide a convenient catch-all for providers
|Oppositional defiant disorder is stigmatized
|African American males
|Long-term negative implications
|Assessment, diagnosis and treatment
|Family, community and other contextual considerations
|Mental health counselor bias
|Cultural and contextual integration
Findings suggested that the assessment time allotted by insurance companies to diagnose a mental disorder undermines the diagnostic process and invalidates the diagnosis. One participant emphasized, “the client is not going to open up to you within that time frame; this is the first time the child is ever seeing you. Those types of things progress over time.” Further structural and systemic assessment problems also were identified by another participant:
You’re allowed to do one assessment per year for the client . . . The assessor would take the previous assessment, use a majority of that information, and then just ask what has changed between then and now . . . there [are] a lot of questions that the previous assessment didn’t answer or didn’t really look into. So that piece gets missed.
Oppositional Defiant Disorder Diagnostic Criteria
The DSM-5 criteria for ODD are too general, providing a convenient catch-all for providers. Symptoms of ODD align with typical child and adolescent behavior as well as other childhood disorders (e.g., ADHD), adjustment disorder, depression and anxiety, depending on developmental context (APA, 2013). Every participant expressed the relative malleability of the ODD criteria. “It’s an easy diagnosis for most people to fit into that category, if they’re having trouble with the legal system and there’s nothing else going on,” noted one participant. Another added that ODD “serves as a holding cell for behaviors that are not understood.” Finally, one mental health counselor stated:
There are no differentials for ODD. It’s all under this blurry category of disruptive behaviors. On one hand it looks easy to diagnose, but on the other hand it’s very complicated when you are not ethically doing the right thing.
Oppositional Defiant Disorder Is Stigmatized
An ODD diagnosis carries negative social weight and judgment within and beyond the mental health fields. African American males are particularly vulnerable to diagnostic stigmatization due to multiple marginalizations that can occur when intersecting with other forms of oppression, such as racism (Arrendondo, 1999; Ratts et al., 2015). Most participants referenced long-term negative implications for these clients, including, “I think it leaves a permanent scar, with elementary kids all the way up.” One participant expressed further that:
I have had kids that have been diagnosed with [ODD] and they drop out. I have had young African American boys in my office and they say ‘You know this has been going on with me since I was a kid?’ And you know that they are telling the truth. They ask themselves, ‘Why am I still in school?’ So they drop out.
Another mental health counselor added:
I see it when we go to court even [with] an African American judge. African American boys would typically get a harsher sentence. It’s a systemic issue. We just start viewing through a lens and we automatically have an assumption to what the problem is. We have a negative interpretation of one kid’s actions versus another.
Assessment, Diagnosis and Treatment
Assessment, diagnosis and treatment do not account for family, community and other contextual problems affecting the client’s mood and behavior. One mental health counselor explained, “if the parent has been incarcerated, they are going to act out. If they are dealing with a domestic violence situation in their home, this is a way of relieving stress for them.” Another participant added:
We leave the whole family out of this process . . . That may be where the problems exist. It is person centered to a fault. To the neglect of it being family centered versus person centered or being both, because you would dare not want to intervene with a child and not involve family. Despite [that] the parents will come and say, 95% of the time, ‘I am okay—you need to fix my son or daughter.’ When treatment plans get tailored based on that premise, then everybody is in trouble.
Trauma also was identified as a contextual issue that warrants consideration in the diagnostic process.
Past trauma, living in very difficult situations, near or below poverty are not taken into account. What might be very adaptive behaviors for a kid, or might be situational dependent, are then just translated into the diagnosis.
Participants acknowledged mental health counselor bias plays a role in diagnosis as well. A mental health counselor may have a tendency to diagnose certain clients with ODD because it is a familiar and commonly used diagnosis. One mental health counselor stated, “a lot of times, particularly with new clinicians, [ODD] is a buzz word . . . like ADD was a buzz word years ago.” A different participant shared the diagnostic rationale, “it helps them, too, because it’s a relatively non-offensive diagnosis. It’s not as personal a diagnosis, so they don’t feel as bad being diagnosed oppositional defiant disorder as they would something else.”
The relative cultural competency of practitioners also was referenced by participants as potentially compromising the diagnostic process, with one indicating that:
When I think about oversight and training, it’s limited in terms of how much exposure they’ve had to diversity training or multiculturalism. What might present as disrespect or non-compliance might be very culturally appropriate . . . The assumption is made that these things are all dysfunctional for the individual as opposed to other contextual factors that are going on.
The purpose of this study was to understand the diagnostic processes and implications associated with ODD. Findings suggest that a diagnosis of ODD can result from more factors than client symptoms fitting the diagnostic criteria. While none of the research or interview questions asked specifically about the role of insurance or managed care, every participant indicated that third party billing influenced the diagnostic process.
Specifically, the mental health counselors interviewed were keenly aware of the necessity of making a diagnosis for insurance reimbursement. It appeared that ODD is considered a reliable diagnosis for billing purposes; however, diagnostic necessity may also create an ethical dilemma for mental health counselors who want to provide quality care and need to earn a living. The possibility of racial diagnostic bias remains, even with insurance requirements, when African Americans are more likely to receive a diagnosis of ODD, while White Americans presenting with similar symptoms receive a diagnosis of adjustment disorder (Feisthamel & Schwartz, 2009; Schwartz & Feisthamel, 2009).
Professional ethical standards and best practices warrant full consideration of a diagnosis, including the purpose served and implications, as related to the health and well-being of clients (American Counseling Association [ACA], 2014). Even when a diagnosis is not warranted or conflicts with theoretical, philosophical or therapeutic approaches, mental health providers serving clients who do not pay cash for services are forced to accommodate diagnostic requirements. The use of a diagnosis as a therapeutic tool, designed to act in concert with others, has also come to serve as the gateway to mental health care services.
In the case of African American male clients, an ODD diagnosis can be particularly stigmatizing with immediate and long-term implications for marginalization and tracking (Cossu et al., 2015). Educational, judicial and incarceration data clearly demonstrate that African American males are disproportionately suspended and expelled from school compared to their peers (U.S. Department of Education Office for Civil Rights, 2014); receive harsher sentences in judicial systems for the same offenses as other defendants (Ghandnoosh, 2014; Rehavi & Starr, 2012); and are more likely to be stopped, searched, assaulted and killed by police officers than other community members (Gabrielson, Jones, & Sagara, 2014; Weatherspoon, 2004). Since ODD is categorized as a disruptive behavior disorder, it may be considered, intentionally or unintentionally, a justification, rationale or explanation for these disparate outcomes. When the diagnosis of a mental disorder is used for purposes other than helping the client, it opens the door to unintended and problematic consequences.
The assessment process is critical to making an accurate diagnosis and should not be limited to the most readily available, convenient or confirmatory information. With ODD, alternative, viable explanations for client symptoms have to be considered that may include family history and dynamics, personal trauma and social–cultural context. Guindon and Sobhany (2001) noted, “often there are discrepancies between the counselor’s perception of their clients’ mental health problems and those of the clients themselves” (p. 277). Again, there may be a tendency to diagnose African American males with perceived behavioral problems with ODD without full consideration of historical and contextual variables that may better explain mood and behavior and warrant a different diagnosis altogether (Hays et al., 2010).
Mental health counselors also have certain biases, within and beyond personal awareness, that create diagnostic tendencies, which may undermine the diagnostic process and invalidate the results of the assessment. Assessment practices and structures appear to accommodate intrinsic and individual information, more so than extrinsic and systemic variables (Hays et al., 2010). For these reasons, the gathering of client information for diagnostic purposes must be as comprehensive and inclusive as possible, notwithstanding measures to limit mental health counselor bias, such as supervision and consultation.
The ACA Code of Ethics outlines the need for even the most experienced counselors to seek supervision and consultation when necessary (ACA, 2014). One potential blind spot for many counselors experiencing bias toward African American male clients is not realizing the need for supervision and consultation when it arises. Understanding that ODD diagnoses within the African American male community have been shown to be inflated is a first step toward decreasing counselor bias. Second, recognizing the subjective nature of making an ODD diagnosis, especially since many of the behaviors and emotions listed as diagnostic criteria also “occur commonly in normally developing children and adolescents” (APA, 2013, p. 15) is another critical aspect of ensuring accurate diagnoses are made.
Counselors are trained from a multimodal approach to diagnosis based on Western medicine; therefore, diagnosing clients is a culturally-based practice (Sue & Sue, 2015). Furthermore, most research in the area of mental and behavioral health has, in large part, not included people of color (U.S. Department of Health and Human Services, 2001). Cultural discrepancies also are evident in the demographic characteristics represented within the counseling profession. Approximately 71% of counselors in the United States are women, and only 18.4% of counselors identify as Black or African American (U.S. Department of Labor, 2015); therefore, most African American male clients will likely have different cultural backgrounds from their counselors. These factors create a need for consultation and supervision to ensure that the personal and professional worldviews of counselors are not inhibiting accurate diagnosis and treatment planning for African American male clients.
In addition to supervision, another measure to limit counselor bias would be to practice reflective cultural auditing, a 13-step process for walking counselors through how culture may impact their work with clients from initial meeting through termination and follow-up. This process allows counselors to reflect on what may seem like client resistance, but may instead be a “disruption in the working alliance” (Collins, Arthur, & Wong-Wylie, 2010, p. 345) based on cultural differences. In addition to utilizing reflective audits of individual cases, it also can be helpful for counselors to review case files regularly, taking into account race and ethnic background, along with symptoms and reported diagnosis. Finding diagnostic patterns within one’s own practice can help counselors reflect on their clinical work and identify areas of bias that may exist.
Implications for Professional Counselors
Thinking through the diagnostic process and beyond the diagnosis requires the mental health counselor to consider and balance the needs of the client, provision of ethical and effective mental health services, expectations and requirements of employers, and earning a living. The following recommendations are offered to help mental health professionals balance these diagnostic considerations in light of current findings, particularly in the assessment and diagnosis of ODD.
In order to make an accurate diagnosis, billing considerations should not be a determining factor in the assessment process. We acknowledge that payment for services is a necessary component for earning a living as a mental health counselor; at the same time, there is an inherent conflict of interest between ethical diagnostic practices and billing when they are not considered as separate processes. Counselors can reference the ACA Code of Ethics (2014) regarding cultural sensitivity (Section E.5.b) as well as historical and social prejudices in the diagnosis of pathology (Section E.5.c). Additionally, counselors may reference the guidelines for informed consent in the counseling relationship (Section A.2.b), ensuring that clients are aware of how information in their client records will be used and how it may impact clients in the future. When appropriate, counselors may choose a less stigmatizing diagnosis initially (e.g., adjustment disorder), while continuing to learn more about a client’s context and cultural background before making a final diagnosis.
Consider extrinsic and external factors that may contribute to emotional and behavioral symptoms presented. It is important to keep in mind that a pattern of ODD behavior includes anger and irritability, argumentative and defiant behavior, and/or vindictiveness, which causes significant problems at work, school or home, and lasts at least 6 months. In order to qualify as ODD symptoms, these behaviors must occur with at least one person who is not a sibling, and must occur on their own (i.e., not as part of another mental health problem, such as depression, anxiety, antisocial behavior and substance abuse disorders). If family history and dynamics, personal trauma and community/contextual factors contribute to any of the above systems, a diagnosis of ODD may not be the most accurate, thereby leading to ineffective, if not harmful treatment plans and outcomes. A diagnosis of adjustment disorder may be more beneficial to ensure that the client receives adequate treatment, which would hopefully increase the client’s chances of having a positive counseling outcome.
African American males are diagnosed with ODD at a disproportionately higher rate than other social demographic groups (Feisthamel & Schwartz, 2009). Ethical and best practice standards require mental health professionals to understand personal biases that might inform their work as well as to develop strategies to reduce or eliminate negative impact (ACA, 2014; Ratts et al., 2015; Sue et al., 1992). In addition, mental health counselors need to use continuing education to remain aware of current trends in the field relevant to the populations they serve (ACA, 2014; Ratts et al., 2015). Health professionals should adhere to diagnostic criteria and integrate multicultural counseling competencies in order to avoid making decisions based on pre-defined misconceptions.
Implications for Counselor Educators and Supervisors
Included in the Council for Accreditation of Counseling and Related Educational Programs (CACREP) accreditation standards is the responsibility of counselor education programs to train students on “the effects of power and privilege for counselors and clients” (CACREP, 2016, p. 9). It is imperative that counselor educators provide specific training on racial bias among counselors, which often is automatic and hidden from conscious awareness (Abreu, 2001).
Creating a safe, comfortable, respectful classroom environment in which students are able to honestly self-reflect and ask questions is necessary to integrate and infuse multicultural and social justice counseling competence training within counselor education programs (Ratts et al., 2015). Counselors-in-training need the opportunity to think critically and experience cognitive dissonance in the classroom regarding ways African American males are portrayed and the erroneous assumptions often made by authority figures and institutions of power. In turn, counselors need to be aware of how these portrayals and assumptions potentially impact the mental health services African American males receive.
In addition to didactic teaching, experiential exercises also are critical for meaningful learning to take place (Sue & Sue, 2015). Assignments that illustrate personal and systemic prejudice can help students reflect on their own potential biases as well as build awareness of systemic influences that may impact clients of color in ways counselors-in-training previously had not considered. Reading assignments that illustrate common biases among counselors can normalize the phenomenon in ways that facilitate student openness to learning and self-reflection. In addition, using diverse theories when discussing diagnosis and treatment planning can ensure multiple perspectives are acknowledged, including the perspective that diagnoses can be both helpful and harmful to clients. Counselor educators have a responsibility to ensure students graduate with an awareness of the need to constantly monitor their own biases and prejudices toward African American males, as well as knowing when to seek supervision and consultation.
Finally, counselor educators can implement a multicultural competence approach to teaching clinical assessment and diagnosis. Guindon and Sobhany (2001) offered a conceptual framework that can be utilized in the classroom in order to achieve this goal: (a) obtain a specific and complete understanding of the client’s chief complaint, (b) be aware of discrepancies in counselor and client perceptions of clinical reality, (c) elicit clients’ clinical realities and explain counselor clinical models, (d) engage in active negotiation with the client as a therapeutic ally, (e) recognize the importance of renegotiation (of perception of presenting problem), and (f) use assessment instruments advisedly and with caution. The authors intended for this framework to be used by “counselors from any cultural background [to] assist those who are not like themselves” (Guindon & Sobhany, 2001, p. 279).
Limitations of the Study
The CQR model allowed the research team to independently and collaboratively analyze the data through a deliberate, thorough and comprehensive process over time to understand the meanings. Multiple perspectives and the relational dynamic within our team helped to check our own biases and to clearly grasp the view of our participants. The findings of this study represent an in-depth analysis of the perspectives of six licensed mental health professionals with experience diagnosing and working with clients who are diagnosed with ODD that may apply to some degree to working with similar populations and contexts. Life and professional experiences of the researchers and participants, however, naturally interact and influence our understandings of the meanings of the data. As such, different combinations of research team members, participants, or contexts could reveal similar, additional or different findings in a similar study. Finally, two graduate student members of the initial research team graduated before data analysis commenced; therefore, we had fewer coders than originally planned. Additional coders would have provided other perspectives on the data and may have further enhanced the meaning-making process.
Conclusion and Future Research
A mental health diagnosis such as ODD has destructive potential when not used properly. Professional counselors, then, have social power in their capacity to diagnose a client with a mental disorder (APA, 2013; Prilleltensky, 2008). Such power requires that counselors cultivate awareness of personal and professional biases that may influence the diagnostic process. Factors driving the diagnostic process extend beyond the mental health needs of the client and can play a critical role in assessment. Contextual explanations, including historic and systemic contexts, must be considered before a diagnosis is given. Attending to the role of counselor bias to prevent overdiagnosis is an ethical responsibility for which counselor educators and practicing counselors must hold themselves accountable.
Additional research is needed to consider whether the diagnosis–billing model is the most optimal and ethical for mental health care, particularly for preventive mental health and for African American male clients and other marginalized populations. Further study also is warranted to capture the long-term implications of an ODD diagnosis, including identifying ways in which a client‘s family can advocate for school and community resources (e.g., outpatient counseling, mentoring programs, support groups). Finally, possible relationships between an ODD diagnosis, school discipline practices and crime adjudication with marginalized groups (e.g., African American males) should be explored, given the drop-out-of-school-to-prison pipeline that is now widely recognized as a reality for many African American males (Barbarin, 2010).
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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Marc A. Grimmett is an Associate Professor at North Carolina State University. Adria S. Dunbar is an Assistant Professor at North Carolina State University. Teshanee Williams and Cory Clark are doctoral students at North Carolina State University. Brittany Prioleau and Jen S. Miller are licensed professional counselors. Correspondence can be addressed to Marc. A. Grimmett, Campus Box 7801, Raleigh, NC 27695-7801, firstname.lastname@example.org.
Oct 6, 2014 | Article, Volume 2 - Issue 2
Mashone Parker, Malik S. Henfield
The purpose of this qualitative study was to examine school counselors’ perceptions of vicarious trauma. Consensual qualitative research (CQR) methodology was used. Six school counselors were interviewed. Three primary domains emerged from the data: (a) ambiguous vicarious trauma, (b) support system significance, and (c) importance of level of experience. Supervision, discrepancies with burnout, and implications for counselor educations and school counselors are discussed.
Keywords: vicarious trauma, consensual qualitative research (CQR), school counselors, support system, counseling experience
Trauma occurs after a person experiences an event that involves or threatens death or serious injury, or a threat to self or other’s well-being (Trippany, White Kress, & Wilcoxin, 2004). Exposure to traumatic events and psychological stress has been found to be associated with significant physical and mental health concerns (Briggs-Gowan et al., 2010). Children and adolescents, particularly those growing up in poverty-stricken areas, are increasingly susceptible to traumatic events such as bullying (Lawrence & Adams, 2006; Newman, Holden, & Delville, 2005), community violence (Fowler, Tompsett, Braciszewski, Jacques-Tiura, & Baltes, 2009), and abuse (Reilly & D’Amico, 2011). For example, children ages 12–17 have been found to be more than twice as likely as adults to be victims of serious violent crimes (Snyder & Sickmund, 2006). Furthermore, every year millions of children and adolescents in the U.S. are exposed to violence in their homes, schools and communities (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009). In addition, according to recent reports, homicide and suicide were found to be the second and third leading causes of death for persons ages 15–24 (U.S. Department of Health and Human Services, 2008–09).
Whether working in a school or mental health setting, there is a chance that a professional counselor will work with an individual who has experienced trauma (Trippany et al., 2004). School counselors, however, by virtue of working in schools, have even more direct contact with youth who may have been exposed to traumatic events. As a result, they are likely to be the first counseling professionals with whom traumatized students come into contact. Functioning as the first line of intervention for students in crisis makes the school counseling position one of vital importance to students’ positive development (Chambers, Zyromski, Asner-Self, & Kimemia, 2010). Exposure to students who have experienced trauma puts school counselors at particular risk for internalizing students’ emotions associated with traumatic events. This process of internalization is otherwise known as vicarious trauma (VT), which is associated with professionals developing harmful changes in their view of themselves, others and the world (Baird & Kracen, 2006).
If a counselor begins to over-identify with a client’s issues they can experience the client’s pain, sadness or distress (Skovholt, 2001). McCann and Pearlman (1990) found that some counselors experienced symptoms similar to those associated with Post-Traumatic Stress Disorder (PTSD) such as nightmares, anger and sadness related to their clients’ traumatic experiences. Clinicians working with sexual abuse victims, for example, may experience feelings of stigmatization and isolation which may be closely aligned with clients, the actual victims of the abuse (Canfield, 2005). Little is known about counselors’ ability to manage VT (Harrison & Westwood, 2009), but some extant literature can be reviewed.
For example, factors such as level of experience (Way, VanDeusen, Martin, Applegate, & Jandle, 2004) and educational training (Adams & Riggs, 2008) impact the prevalence of VT. Seminal articles examining VT concluded that counselors with more clinical experience have a buffer in preventing VT (Pearlman & Mac Ian, 1995). Adams and Riggs (2008) conducted a study with 129 therapist trainees. The purpose of their study was to explore the relationship between vicarious traumatization among trainees and variables recognized as potentially influential in this process among practicing therapists (i.e., history of trauma, clinical experience, trauma-specific training), and to explore the relationship between defense style and vicarious traumatization symptoms, as well as its possible interaction with the previous three factors in relation to reported symptoms. Consistent with previous research, the researchers found that novice therapists/counselors may be more vulnerable to experiencing VT (Adams & Riggs, 2008).
Level of peer support and supervision also play a role in buffering symptoms of VT (McCann & Pearlman, 1990). Supervision practices that address VT have been encouraged (Woodard, Meyers, & Cornille, 2002). Specifically, trauma-sensitive supervision is seen as helpful in minimizing the effects of vicarious exposure to trauma (Sommer & Cox, 2005). As Sommer and Cox (2005) conclude, multiple perspectives, collaboration, a calming presence and attention to self-care are most helpful when examining the supervisee’s perspective of adequate supervision. Clinicians must work through painful experiences in a supportive environment. McCann and Pearlman (1990) have suggested that weekly case conferences can be helpful for clinicians that use two-hour weekly support groups aimed at conceptualizing difficult victim cases (with client consent) and exploring personal meaning for themselves related to how they respond to the painful experiences of their clients. Other studies have identified coherence and organizational support as being linked to positive responses to stress (Linley & Joseph, 2007).
There is some overlap between conceptualizations of VT and burnout (McCann & Pearlman, 1990). Burnout is described as the result of the stress that working with difficult clients can produce, and is seen as having three content domains: emotional exhaustion, depersonalization and reduced personal accomplishments (Jenkins & Baird, 2002). There lies a feeling of complete overload which in turn may affect the counselor’s work performance. Burnout also can be described as a general reaction to feeling overwhelmed, where vicarious trauma is related to specific traumatic events. Moreover, Trippany et al. (2004) shared that many counselors who work with trauma patients may experience burnout and vicarious trauma simultaneously.
Most research related to VT focuses on mental health counselors and social workers. Little, if any, published research literature has examined this phenomenon among school counseling professionals. Exposure to a child’s trauma is usually described as more challenging for professionals when compared to adult trauma (Figley, 1995). Therefore, school counselors, by virtue of their work setting, may be at great risk for experiencing VT.
The primary purpose of this study was to investigate counselors’ knowledge and perceptions of VT. The information gathered in this project will increase the level of understanding and awareness of vicarious trauma on school counseling professionals, allowing school counselors to implement strategies to ameliorate the effects of vicarious trauma.
Participants were individuals who met either one of two criteria: (a) persons licensed or certified as a school counselor, and/or (b) individuals endorsed as a school counselor and currently working in a school. Six school counselors ranging in age from 27 to 54 were recruited from schools located in a midwestern state (3 females and 3 males). Participants worked at least part-time with 3 to 14 years of counseling experience. Four of the six participants graduated from a master’s degree program accredited by the Council for Accreditation of Counseling and Related Educational Programs. All participants were European-American. In addition to school counseling experiences, participants had a range of other work experiences including mental health and social work.
Due to the exploratory nature of the study, convenience sampling procedures were used to recruit participants (Marshall, 1996). A recruitment e-mail was sent to individuals on listservs serving school counselors in a midwestern state. Those interested in participating in the study replied to the e-mail indicating their desire. Once the e-mail was received by the primary researcher, participants were e-mailed a consent form and asked to sign and return it to the primary researcher. A verbal consent was then given at the beginning of each interview.
One phone or Skype interview was conducted with each participant. Each participant was emailed a copy of their transcriptions verbatim (member checking) to ensure participants’ voices were being heard and interpretations were accurate. Through member checking, participants were able to identify areas that may have been neglected or misconstrued (Lietz, Langer, & Furman, 2006); all participants verified the interviews were accurate. Asking for participant feedback helps build rapport between the researcher and participants and establishes trustworthiness (Williams & Morrow, 2009).
As Patton (2002) writes, qualitative researchers are the major instrument of data collection, and their credibility is critical. The research team consisted of two individuals: a counselor education doctoral student (primary researcher) and an assistant professor in counselor education. An advanced counselor education doctoral candidate served as an auditor, whose role was to verify findings developed by the research team (Patton, 2002). One researcher had prior experience performing CQR investigations.
Trustworthiness refers to the quality or validity in qualitative research (Morrow, 2005). Staying aware of biases related to being a human instrument (Patton, 2002), as well as avoiding getting enmeshed in the data are important for qualitative researchers. Biases may arise from demographic characteristics of the researchers or values and beliefs about the topic. One potential bias for the study was one team member being familiar with the research on VT and possibly having preconceived expectations before analyzing data. The use of a research team of two researchers helped foster multiple perspectives (Hill et al., 2005). An external auditor and member checking strategies also were employed to ensure trustworthiness of the data (Patton, 2002).
The purpose of the external auditor in CQR is to ensure that the research team did not overlook important facts in the data (Hill, Knox, Thompson, & Nutt-Williams, 1997). During the data analysis process, the researcher engaged in an audit trail that described the specific research steps. An audit trail is an important part of establishing rigor in qualitative work as it describes the research procedures (Johnson & Waterfield, 2004). This audit trail was given to the external auditor who verified domains and core ideas.
Based on a review of current literature on vicarious trauma, a semi-structured interview guide was constructed. The interview guide included demographic questions as well as open-ended topics related to participants’ perceptions and understanding of trauma in relation to its impact on school counselors. Some examples of interview questions used are as follows: How do you define Vicarious Trauma (VT) of counselors? To what degree is VT a problem in the counseling profession? And, who do you believe to be at greater risk for experiencing VT? Specifically, the study was concerned with gaining an understanding of how participants perceived the importance of VT as an issue in the school counseling profession. Interviews were conducted by either Skype or telephone as a cost-effective means of collecting data (Hill et al., 1997). Each interview lasted 30 to 60 minutes. All interviews were taped and transcribed verbatim.
The data were analyzed according to CQR methodology (Hill et al., 1997). In CQR, the goal is to arrive at a consensus along with other research team members regarding data classification and meaning. Grounded theory was the most influential theory in developing CQR. Although CQR combines aspects of various qualitative approaches, there are some factors that differ and provide its uniqueness. For example, unlike grounded theory, CQR emphasizes the use of research teams rather than one judge (Hill et al., 1997). CQR researchers also code data in domains (i.e., themes), then abstract the core ideas of each participant. Coding of the data was completed individually by the research team. Each researcher read all transcribed interviews and wrote what he or she thought to be the core ideas that captured each interview. Categories were developed from core ideas across all participants within each domain (Hill et al., 2005). These core ideas were identified as pertinent in the lives of these school counselors and were verified by the external auditor. Categories mentioned by all participants (i.e., all six counselors) were thought to be “general.” Those categories with more than half, but not all of the respondents were considered “typical” (i.e., 4–5 out of 6 counselors); those with half or fewer respondents were considered “variant” (i.e., 2–3 out of 6 counselors). Next, a consensus was reached regarding the core ideas captured from the data, followed by the auditor examining the resulting consensus and assessing the accuracy of the coding and core ideas. Finally, the research team reviewed the auditor’s comments to verify all findings (Hill et al., 1997).
This section outlines three domains that emerged from the data: (a) ambiguous VT, (b) support system significance and, (c) importance of level of experience. These findings shed light on participants’ perceptions of the meaning of VT, as well as ways to avoid it and effectively respond to it should it occur.
Vicarious Trauma Ambiguity
In general, participants had an idea of what VT entailed, but for the most part it was ambiguously defined. One participant referred to it as taking on the issues that students or clients have and “carrying those things home.” Also, the counselor explained it was about living the experiences clients are living. Another counselor reported that VT occurs without realization.
Participants’ past experience was indicative of their understanding of trauma and VT. Specifically, those individuals who had previous social work careers (two participants) or a mental health background (one participant) had a greater knowledge of VT and its effects. They reported having more trauma training in their previous graduate programs when compared to their school counseling programs.
Typically, participants stated that they did not know much about VT, with three counselors reporting it to be synonymous with burnout. One counselor shared that VT was learned after participating in a research study exploring the topic. Another counselor shared that he did not have a clear understanding of VT, but assumes it refers to how he reacts to students with serious issues. Burnout was mentioned sporadically, but for some the concept served as a key feature of their understanding of VT. For example, one participant stated not knowing a ton about the topic, but understanding it as burnout, as did another participant. One counselor shared that VT was viewed as transference and that transference was something often discussed in graduate school.
Support System Significance
In general, school counselors reported that support systems are significant and needed to help alleviate vicarious trauma symptoms, or prevent it from occurring. Typical reports suggested they viewed peer supervision as quite useful for dealing effectively with VT. For example, one participant stated the importance of having others around who are willing to tell you when you are too close to a case. Another participant responded that counselors also have to be willing to accept an evaluation from staff members and others with similar career experience. Similarly, one participant discussed obtaining ongoing support from various avenues within the school environment to prevent her from experiencing VT. This counselor noted providing time for counselors to be with one other in a group setting or one-on-one consulting as a particularly good way to garner support for school counselors. This participant thought supervision would be helpful, but was not sure how to go about seeking it. Essentially, finding time to talk through issues was the most helpful thing to do according to this participant.
Someone or something to help unwind was viewed as a significant means of support. Participants explained that support also can come in the form of family or those not involved with the mental health profession at all. Furthermore, one participant noted that having an outlet such as an athletic or creative activity could be viewed as a form of support as well.
In addition, another participant shared the importance of a supportive work environment. According to this individual, without a healthy work environment VT can easily occur. Other participants also spoke of experiences with administrators and other staff at their workplace. For example, one participant addressed this support, sharing the fortune of having an administrative team to watch one another. They discussed keeping an eye out on issues and problems that colleagues may be experiencing, including VT.
Interestingly, participants also suggested that separation between work and home also has the potential to help alleviate these symptoms. According to one participant, “you must leave your hat at the door,” while another stated that once home, it was necessary to decompress and separate from work. Another school counselor felt as though technology created a hindrance in the separation of school and work. This participant felt that counselors should give themselves permission to separate themselves from work if they so desire. It was recommended that school counselors be given permission to separate themselves from work by not being forced to respond to e-mails and other forms of communication once arriving at home. As this school counselor noted, people have the ability to make contact at any time of day if they are allowed. This participant felt it is important not to give out phone numbers, or only give a personal number to those you trust will not abuse it.
Level of Experience
Generally, participants agreed that level of experience determined counselors’ risks of experiencing VT. Experience was perceived in a number of different ways ranging from formal training to work/life experience, with all participants mentioning how either life or work experiences helped them avoid or overcome VT.
Relatedly, many participants also discussed how either a lack of training or the need for more training could be related to how school counselors experience VT. Five out of six participants discussed the importance of receiving more training, or having an open discussion about their negative reactions to other colleagues or supervisors. Three out of six counselors shared that they had no classes related to trauma from their school counseling training. As one participant stated, not much training was offered and they wished more classes could have been taken on VT. A lack of life experience also was said to place a novice counselor at great risk for VT. One participant voiced concern about a student going straight into a master’s program with little life experience. Concern was voiced about students that go straight from a baccalaureate to a master’s program without taking time to live and work. According to this participant, inexperienced school counselors are unaware of the challenges they will face upon entering the counseling profession and may be more susceptible to VT. Similarly, another participant talked about how her relationship to the profession changed after four years as a school counselor. This school counselor discussed going home really frustrated or angry, feeling like more should have been done for students when starting out as a school counselor. Eventually, this counselor noted that work as a school counselor started to come together and that patience was important when working with children. This school counselor discussed frustration and anger as being signs of VT. This individual also felt that after more experience in the counseling field, symptoms such as these begin to vanish.
One participant mentioned a desire to save the world after graduation, which is typical of most new school counselors, but did not always work in the counselor’s favor. This individual felt that it only made the job more difficult when he realized he could not save every child he encountered. Another participant shared that new school counselors are often shocked because they haven’t seen as many issues as more seasoned counselors. However, this participant also shared that working with the issues kids face became easier each year, and the shock associated with hearing students’ issues decreased.
The purpose of this study was to explore school counselors’ knowledge and perceptions of VT. Consistent with the literature regarding preventive and protective measures of VT (Adams & Riggs, 2008), these counselors named newer helping professionals as particularly susceptible to VT. They also discussed factors such as types of support systems and amount of experience with VT as playing a role in preventing VT. This finding is consistent with the research as well, which concludes that as level of support and work experience increase, the counselor is less likely to suffer from VT (Chrestman, 1999; Skovholt & Ronnestad, 2003; Sommer & Cox, 2005). All participants mentioned collaboration with other counselors as a primary means of averting VT. This finding suggests that counselors look to one another for assistance. Forming peer groups and having consultations with other staff within the school environment appeared to be vital in the lives of these participants. McCann and Pearlman (1990) support this notion and have stated the importance of counselors seeking potential sources of support in their professional networks, and that activities such as case conferences can be beneficial to counselors.
Participants proposed that lack of training on the topic made them more susceptible to experiencing VT, which is supported by literature on VT (Pearlman & Saakvitne, 1995). Studies have indicated that as level of experience, education and post-graduate training increases, trauma symptoms in counselors decrease (Adams & Riggs, 2008; Sommers, 2008).
School counselors discussed the difficulty associated with being a beginner counselor and how, with experience, one learns to set boundaries as a method of protecting oneself from VT. They also shared the strong relationship between life experience and being an effective counselor, which is vital to warding off VT symptomology. This finding is consistent with the literature that concludes that newer, more novice therapists may be more vulnerable to experiencing VT (Adams & Riggs, 2008). Many participants discussed how their level of confidence in their work increased over time. Previous literature and findings from the current study suggest that newer professionals may need more support for VT when starting their careers. Scholars have referred to helpful practices such as conferences (McCann & Pearlman, 1990), support groups or supervision (Sommers & Cox, 2005) as useful.
Supervision, although discussed in the literature as an alleviating factor in preventing VT (Sommers & Cox, 2005), was not salient in the current study. Only one participant discussed supervision as playing a role in preventing VT. The other school counselors did discuss that support from peers and administrators were helpful, but not supervision practices. This is worth mentioning, as supervision is one of the key methods counselor educators use to train counselors. It is not known if these counselors viewed support as part of supervision or if they do not see this as being available to them. For example, one participant spoke about an interest in forming peer supervision groups, but did not feel knowledgeable enough to do so.
Some participants stated they did not know much about VT, while others assumed it was similar to burnout. Vicarious trauma and burnout, although sometimes used simultaneously throughout the literature, have some differences in how each is displayed. Burnout may progress gradually, whereas vicarious traumatization can sometimes seem abrupt in onset with little or no knowledge of early recognition (Jenkins & Baird, 2002). Participants who compared VT to burnout did not distinguish any differences in the two constructs. Although not the focus on this study, one participant mentioned personally experienced symptoms related to VT (which this participant described as burnout). This finding suggests that counselors are aware of both VT and burnout. Burnout is a term documented throughout the literature, making it more accessible to counselors’ understanding of occupational stress and hazards.
The findings suggest that counselors feel unprepared to work with trauma cases due to lack of training in their master’s programs. Although the counselors in this study were able to form a working definition of what VT entailed, they wished they possessed more knowledge on the topic. What is important is that these counselors reported that with adequate support from one another they can help prevent or alleviate symptoms of VT. These school counselors also felt that as they become more settled in their profession, they are more apt in dealing with difficult case loads. This suggests that novice counselors should receive more support from colleagues, administrators and others in their professional network. The changes that occur when a counselor experiences VT may have a direct impact on the students they serve, therefore making it salient to address in both the school counseling profession as well training programs.
Implications for Counselor Educators and School Counselors
School counselors make an outstanding contribution to our society through serving our children. An awareness of VT may allow school counselors to implement strategies to ameliorate its effects. The information gathered in this project will increase the level of understanding and awareness of VT on school counseling professionals. VT is a phenomenon that has gained increasing attention in the counseling literature (Hafkenscheid, 2005; Harrison & Westwood, 2009; Sommer, 2008; Way et al., 2004). The findings seem to suggest school counselors feel they lack adequate knowledge and training regarding VT.
Findings from this study also suggest that it would be useful for counselors, especially those working with trauma survivors, to gain more knowledge and awareness on the topic. Counselor educators should offer more training in their counseling programs to increase awareness of VT and other trauma-related topics. For instance, school counselors in the current study expressed a need for more specific training related to VT or trauma in general. Courses related to trauma may be useful for fostering counselor growth (Sommer, 2008). Supervision also can be a reliable source for providing awareness of VT (Sommer & Cox, 2005) since supervision is used to monitor supervisees’ level of functioning and growth (McCann & Pearlman, 1990; Woodard Meyers, & Cornille, 2002).
The counselors in this study expressed the need for support in their work environments. School counselors should maintain collegial relationships as well as offer support to peers within their work environments. Peer groups, weekly case conferences and consultation may be useful for counselors to maintain their wellness and avoid experiencing VT (McCann & Pearlman, 1990). School counselors are in a good position to initiate support for students in their learning environments because they have direct access to children. Therefore, adequate training of school counselors is essential.
Limitations and Future Research
As with all research, there were limitations associated with the current study. First, Skype interviews may have generated pertinent information; however, such interviews were not feasible or accessible to all participants. Subtleties in body language cannot be accounted for during phone interviews. Future studies could include all Skype or face-to-face interviews. Second, given the limited understanding most participants in this study had on the topic, it may have been difficult for them to understand the prevalence of VT in the counseling field. It is possible that what they described as being VT in other school counselors can actually be symptoms of burnout, which the research concludes is different (Jenkins & Baird, 2002).
The current study provided an overview of the phenomenon and also some implications for both school counselors and counselor educators. There has not been much research supporting specific forms of treatment for VT and it should be examined further in the future. Research examining how individuals overcome symptoms of VT may be helpful for counseling professionals. Such research would provide others in the counseling field with a knowledge base that may be helpful in preventing the phenomenon. Since research on VT tended to focus on mental health professionals, social workers or trauma workers, future studies could specifically focus on preventative strategies for school counselors. Such information may elicit responses that capture how school counselors understand and experience VT, which could offer a clearer picture of what training programs can do to recognize and prepare for combating VT prior to entering the profession.
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Mashone Parker, NCC, is a doctoral candidate in the counselor education program at the University of Iowa. Malik S. Henfield is an Associate Professor in the counselor education program at the University of Iowa. Correspondence can be addressed to Mashone Parker, University of Iowa, RCE N338 Lindquist Center, Iowa City, IA 52242, email@example.com.