Dec 5, 2024 | Volume 14 - Issue 3
Russ Curtis, Lisen C. Roberts, Paul Stonehouse, Melodie H. Frick
Tattoo art is one of the earliest forms of self-expression, but the advent of colonialism, and its accompanying religious convictions, halted the practice in many Indigenous lands and led to widespread bias against tattooed people—a bias maintained to the present. How might the counseling profession respond to this residual bias and intentionally invoke a cultural shift destigmatizing tattoos? Through an extensive literature review, this article provides a more comprehensive understanding of tattoo-related mental health correlates, biases, and theories that enhance the effectiveness of counseling and parallel trends in the counseling profession that emphasize sociocultural influences on wellness. As a result of this survey, the authors propose a new theory of tattoo motivation, the unencumbered self theory of tattoos, which advances existing tattoo theory and aligns with current counseling trends by postulating that tattoos symbolize the uniquely human desire to transcend norms and laws imposed by external influences.
Keywords: tattoo, bias, mental health, theory, counseling
Imagine you are the parent of a 13-year-old girl. While at a parent–teacher conference, you learn your daughter is struggling with disruptive behavior and angry outbursts during class. The teacher asks if you would support your daughter seeing the school counselor and adds that the counselor is in the school building and available to speak with parents. You approach the counselor’s office, gently knock, and are welcomed by a warm, feminine-presenting adult. As the counselor offers their hand to shake, you notice an entirely tattooed forearm, and as you greet their eyes, more ink is evident on their neck.
What feelings, assumptions, or concerns emerge as you put yourself in the place of the parent in the above vignette? Despite the recent popularization of tattoos, a bias remains. Current research indicates that nearly half of adults in the United States between the ages of 18–34 have at least one tattoo (Roggenkamp et al., 2017), and the tattoo business is one of the fastest-growing enterprises, producing over a billion dollars in annual revenue (Zuckerman, 2020). This trend in tattoo art transcends the United States and is evident throughout the world (Ernst et al., 2022; Khair, 2022; Roberts, 2016). Nevertheless, bias against tattooed people remains, and women and people of color receive the brunt of this discrimination (Baumann et al., 2016; Guéguen, 2013; Kaufmann & Armstrong, 2022; Khair, 2022; Roberts, 2016). Given this meteoric resurgence in tattoo art and the discrimination that clings to it, implications for counseling practice inevitably exist.
Professional questions relevant to the counseling practice include: Is there a relationship between a desire for a tattoo and mental health? What motivates a person to seek a tattoo? In what ways may a tattoo bias subconsciously shape a counselor’s interactions with a client? How might the counseling community communicate a spirit of inclusion to the tattooed? To address these questions, this article employs the following structure. First, we provide a context for this bias by briefly examining the history and cultural perspectives of tattoos. Second, to establish the importance of this issue, we empirically demonstrate the reality of tattoo bias. Third, with this history of bias in mind, we comb the literature for research that explores the relationship between mental health and tattoos. Fourth, these relationships offer a frame of reference for our survey of established tattoo motivation theories, to which we propose an additional theory, the unencumbered self theory of tattoos, and reveal its significance within a clinical setting via a case study. Fifth, before concluding the article, we demonstrate how our inquiry’s content might be applied by enumerating our argument’s implications for the counseling profession.
Historical and Cultural Perspectives of Tattoos
The word tattoo originates from the Samoan term tatau, meaning “to tap lines on the body.” The practice of tattooing is known to have existed as early as 7000 BC, as seen on Egyptian mummies (Rohith et al., 2020). Otzi the Ice Man, dating back to 3000 BC, was discovered in 1991 with tattoos on his arms and wrist that are thought to have been applied for therapeutic purposes, a potential precursor to acupuncture (Schmid, 2013). Prior to the colonization of Indigenous lands by European countries, many tribes practiced the art of tattoo to symbolize adulthood, tribal membership, and status (Dance, 2019; Thomas et al., 2005). However, with the emergence of European imperialism, colonizers taught Indigenous people that tattoos were an abomination, scripturally prohibited, and therefore immoral. For instance, in The Holy Bible (New International Version, 1978, Leviticus 19:28) and The Qur’an (2004, Surah 7:46), specific passages forbid marking the skin.
Despite these condemnations, the practice of tattooing was not eradicated. Many cultures continued their tattoo traditions, and modern culture has adopted new traditions, which are even now expanding throughout the world (Ernst et al., 2022; Khair, 2022; Roberts, 2016). Although there is much intergroup variability, cultural identity can influence the motivation for and type of preferred tattoo. In India, for instance, tattoos often depict unique patterns specific to different tribal regions in the country. Specifically, in urbanized Indian geographic areas, there is increasing integration of tribal pattern tattoos with Western-influenced designs (Rohith et al., 2020). In Samoan culture, men receive an intricate tattoo called a pe’a while women receive a malu, both to indicate maturity (Dance, 2019). Lest the cultural importance of Indigenous tattoos be doubted, their misappropriation has resulted in litigation, thereby challenging attorneys to consider the property rights of tattoo designs (Tan, 2013).
Profoundly relevant to counseling, tattoos are often representational and symbolize something of importance. In a recent qualitative study of tattooed Middle Eastern women, Khair (2022) discovered themes related to taking ownership of their bodies in a patriarchal society and symbolism of their strength and desire to break free of patriarchal rules and religious mandates. In the United States, a study of mixed-race Americans’ tattoos revealed the most common tattoo themes include animal images and text of personally meaningful messages (Sims, 2018). In yet another group, White supremacists often get swastikas, crossed hammers, Confederate flags, and embellished Celtic crosses (Southern Poverty Law Center, 2006). Similarly, in Czech Republic prisons, the skull tattoo is a symbol representing neo-Nazi extremism, which then informs prison officials of inmates potentially becoming radicalized (Vegrichtová, 2018).
Exploring the intersection of religion and tattoos, Morello’s (2021) qualitative analysis of 21 people in three South American cities revealed that tattoos were more accepted among Catholics than evangelicals. Explained below, Morello classified the types of Christian tattoos as reversal, devotional, foundational, and then a nonreligious fourth category termed relational. According to participants, reversal tattoos symbolized regaining control of disempowering events, such as when Christians historically tattooed themselves to show Roman enslavers their devotion to Christ. Devotional tattoos were comprised of images and symbols representing religious themes (e.g., a cross), often used as a source of strength and identity. Foundational tattoos represent significant moments in life, such as major life transitions (e.g., the date of one’s conversion) or mystical experiences. Morello’s last category is akin to devotional tattoos, but the relational category was created to represent devotion to loved ones, such as images or symbols of one’s children.
In a related study examining the beliefs of religious women with and without tattoos, Morello et al. (2021) identified several common themes. This mixed methods study of 48 women in a conservative Christian college indicated that tattoos were not considered taboo by their religious friends and family and that tattooed participants spent considerable time determining which tattoo to receive. Predominant reasons for obtaining tattoos included social justice, friendship, and spiritual values. Summarizing previous research, individuals primarily choose tattoos to express their identity and uniqueness or to take ownership of their bodies. However, as discussed in the following section, there exists a bias against tattooed individuals.
Tattoo Bias
Unfortunately, with any practice that diverges from dominant cultural values, there is bias (Broussard & Harton, 2018). Although evidence indicates less discrimination against tattoos in the 21st century, negative judgments still exist explicitly and implicitly (Broussard & Harton, 2018; Williams et al., 2014; Zestcott et al., 2018). For example, Kaufmann and Armstrong (2022) found that law enforcement and the medical community hold negative sentiments toward tattooed people. They found that medical professionals who expressed negative judgments about their tattooed patients were likely to have patients not return. In fact, patients reported better rapport and increased trust with medical professionals who asked about the meaning of their tattoos. In other words, negative judgment toward, and lack of acknowledgment of, tattoos were detrimental to building the trust needed to provide optimal and consistent care (Kaufmann & Armstrong, 2022).
Unjustly, women and people of color with tattoos experience more significant discrimination than men or White people (Baumann et al., 2016; Camacho & Brown, 2018; Guégen, 2013; Solanke, 2017). For example, women encounter prejudice when failing to gain employment due to having visible tattoos regardless of having excellent job qualifications (Al-Twal & Abuhassan, 2024; Henle et al., 2022). Moreover, women of color have experienced job discrimination by being questioned if they have visible or nonvisible tattoos (i.e., inkism), being forbidden from having or being required to cover tattoos regardless of cultural relevance (e.g., covering a traditional Māori tattoo), or being required to prove that they do not have tattoos—as alleged in a legal complaint against a Singaporean airline that required female attendants to wear a swimsuit and demonstrate to their employers that they did not have tattoos (Solanke, 2017, Chapter 8). Women with tattoos also experience ambivalent sexism due to rejecting the feminine apologetic (i.e., not acting or dressing in stereotypical feminine ways); they are also perceived as wanting attention and sexually promiscuous (Heckerl, 2021). For instance, Guéguen (2013) found that women on the beach displaying a lower-back butterfly tattoo were significantly more likely to be approached by men compared to women without the tattoo, and the men interviewed indicated that they thought they had a better chance of getting a date and having sex with the tattooed women than the nontattooed women (Guéguen, 2013). In other words, men in this study had the biased perception that women with tattoos were more sexually promiscuous than nontattooed women.
This bias appears within incarceration rates as well. In a study conducted by Camacho and Brown (2018), they found that arrestees with neck tattoos were more likely to receive felony charges specifically for larceny offenses. Among these groups, Black individuals with neck tattoos were more likely than others to face felony charges (Camacho & Brown, 2018). It is also noteworthy that law enforcement catalog the tattoos of arrestees in the Registry of Distinct Marks (Miranda, 2020), which is kept in their permanent record and could potentially bias future incarceration and convictions due to the criminogenic stigmatization of individuals with tattoos (Martone, 2023; Rima et al., 2023).
Neck tattoos specifically appear to elicit bias (Baumann et al., 2016). Given two sets of photos of male and female faces, with a neck tattoo and without a visible tattoo, participants were asked to choose among the photos that they would most like to have as their surgeon. In a separate condition, participants were asked to choose who they would most like to have as their car mechanic. In both experiments, participants preferred to have a nontattooed person as their surgeon or mechanic. However, the preference was more substantial for a nontattooed surgeon than a nontattooed mechanic. Female participants assessed the tattooed faces more positively than male participants, but still preferred the nontattooed faces (Baumann et al., 2016).
Roberts (2016) suggested that although tattoos are becoming more prevalent worldwide, they are not yet entirely accepted. As such, employment discrimination occurs for people with visible tattoos. Roberts (2016) suggested employers discriminate primarily because of the fear of customer complaints and the concomitant loss of business. They further suggested that small businesses in rural areas, which tend to be more conservative, may be even more likely to refuse employment to tattooed workers.
Clients’ Perception of Tattooed Counselors
To date, very few published studies examine the perceptions of tattoos within the mental health professional arena. One exception, however, is a recent publication examining the perception of potential mental health clients of psychologists with or without tattoos. Zidenberg et al. (2022) recruited 534 participants to determine if there were negative perceptions of psychologists who had tattoos. First, participants were presented with a mock profile of a fictional clinical psychologist. Each participant was randomly assigned to view one of three images of the psychologist: with no tattoo, a neutral tattoo (a flower), or a provocative tattoo (a skull with flames). Participants then rated the counselor on perceived competence and their personal feelings toward her.
Contrary to the researchers’ initial expectations, the psychologist’s photo with the provocative tattoo was rated more likable, interesting, and confident and less lazy than the psychologist with a neutral or no tattoo. Interestingly, the psychologist’s photo without a tattoo was rated as more professional, but this did not equate to participants’ believing that the psychologist would thus provide better care. The researchers speculated that while nontattooed people are viewed as more professional, they are not necessarily who clients believe will give the best mental health care. They further hypothesized that professionalism may convey a bias of being “better than” the clients and thereby might be perceived as less authentic. Moreover, participants in this study believed they would get better help from a more “authentic” psychologist, and that the provocative tattoo communicated a sense of authenticity (Zidenberg et al., 2022).
Mental Health and Tattoos
Although early studies (e.g., Grumet, 1983) concluded that tattoos were a sign of maladjustment, contemporary research indicates that tattooed people are as healthy as nontattooed people (Mortensen et al., 2019; Pajor et al., 2015). In general, today the mere presence of a tattoo is not correlated with mental or behavioral issues (Roggenkamp et al., 2017). In fact, most people in many cultures conscientiously obtain tattoos to express themselves and honor people and causes they deeply care about (Khair, 2022; Naudé et al., 2019; Shuaib, 2020). Nevertheless, in one study of a German community (N = 1,060), which sampled people aged 14–44, 40.6% who reported childhood abuse or neglect had at least one tattoo, compared to 29.4% tattooed participants who reported no significant abuse (Ernst et al., 2022). However, Ernst et al. (2022) cautioned that the mere presence of a tattoo is not perfectly correlated with childhood abuse. Aesthetic embellishment of the body is the most common reason for getting tattoos, and it should not be considered an automatic indication of childhood abuse (Ernst et al., 2022).
Evidence suggests that the number of tattoos as well as their placement and content better indicate potential maladjustment than the mere presence of an easily concealed tattoo. Specifically, Mortensen et al. (2019) found that participants (N = 2008 adults) who had four or more tattoos were 15.4% more likely to report having been diagnosed with a mental health problem compared to 5.8% of participants with only one tattoo. Further, 13.4% of the participants with visible tattoos reported having a mental health diagnosis, and 28.2% of the participants who self-reported having an offensive tattoo also reported having a mental health diagnosis. In other words, multiple and visible tattoos may be more closely correlated with mental and behavioral issues than the mere presence of tattoos. However, contrary to Mortensen et al. (2019), in their study of life satisfaction with a sample of 449 participants (16–58 years old), Pajor et al. (2015) used the Multidimensional Self-Esteem Inventory (MSEI; O’Brien & Epstein, 1988), a psychological assessment tool with 116 items graded on a 5-point scale and designed to measure various aspects of self-esteem. Results indicated that tattooed people reported significantly higher competence than nontattooed: 37.2 versus 33.6 (p < .001). Tattooed participants also scored significantly higher on a measure of personal power, 35.6 versus 33.5 (p < .01), and significantly lower scores on a measure of anxiety and insomnia, 1.50 versus 1.75 (p < .05). Thus, although numerous visible tattoos could potentially indicate mental or behavioral issues, the research is not conclusive, suggesting the need for counselors to open-mindedly assess each client’s motivations for obtaining tattoos.
Contrary to previous hypotheses, tattoos are rarely a form of self-harm (i.e., cutting, self-mutilation). For example, Aizenman and Jensen (2007) analyzed a sample of college students (N = 1,330; ages 17–39) to determine mental health differences between students who self-injure and those with tattoos. The majority of tattooed students reported receiving tattoos as a way to express their individuality, while students who self-injured were motivated by feelings of insecurity and loss of control. Participants also completed assessments measuring depression and self-esteem. In terms of general wellness, the self-injury group (no tattoos) reported higher mean depression scores compared to both the tattoo group’s score and the nontattooed (no self-injury) score. The self-injury group also reported lower mean self-esteem scores compared to both the tattooed and the nontattooed groups. Noteworthy is the fact that there was no significant difference between the tattooed and nontattooed groups in terms of depression and self-esteem, which further suggests that tattooed college students are no more likely to experience mental health issues than nontattooed college students.
In a more recent study to determine whether tattooing was a form of self-injury, Solís-Bravo et al. (2019) found that from a sample of 438 adolescent males, 11.5% reported engaging in nonsuicidal self-injury (NSSI), but only 1.8% indicated receiving a tattoo with the explicit intention of feeling pain. However, they also found that 62.5% of the students with tattoos self-injured compared to 10.6% of students without tattoos. Thus, with this small subsample of tattooed NSSI students, it was suggested that tattooed adolescents should be screened for potential mental health issues. Yet, considering that only eight students in this sample reported getting a tattoo to feel pain, further replication of this work is needed before confirming a conclusive relationship between tattoos and NSSI (Solís-Bravo et al., 2019).
Exploring the correlation between tattoos and premature mortality (e.g., violent death, drug overdose), Stephenson and Byard (2019) found that there was a trend for people with tattoos to die at a younger age and to experience an unnatural death compared to nontattooed people. However, these results were not statistically significant, indicating that there was no meaningful difference between age and cause of death between tattooed and nontattooed people.
More contemporary research examined the relationship between body image and tattoo acquisition (Jabłońska & Mirucka, 2023). Using a sample of 327 Polish tattooed women to examine a relationship between body image and tattoos, 45.26% reported acceptance of their appearance and a deep connection to their bodies. Researchers speculated that they received tattoos as a way to adorn their bodies and express their individuality. Another 36% reported an unstable body image, meaning they perceived both positive and negative aspects of their bodies. It was speculated that this group used tattoos to conceal perceived flaws. The remaining 18.65% held a negative body image. Although the majority of their sample held either positive or mixed body image estimations, the researchers’ speculation as to why subjects received tattoos makes it difficult to infer correlation between tattoos and well-being. Nevertheless, nearly half the sample reported appreciation for their bodies and a desire to accentuate their positive self-image with body art.
Relatedly, some trauma survivors get tattoos to symbolize what they experienced and how they have grown (Crompton et al., 2021). The semicolon is one example of this, indicating that while one life chapter may have been traumatic, that is not the end of the story. Using tattoos to navigate trauma is further supported by Kidron (2012), who noted that some descendants of Holocaust survivors replicated the number tattoo on their arms to illustrate the connection to their grandparent, redefining the tattoos from markers of trauma to markers of survival and expanding their interfamilial bond and cultural identity.
In summary, studies indicate that the mere presence of a tattoo is not significantly correlated with mental or behavioral issues. Counselors should avoid assuming that tattooed clients have mental health issues, even if multiple visible tattoos are sometimes linked with adverse health outcomes or behaviors. Because tattoos are so often attached to identity, body image, and important life events, counselors should thoroughly explore with clients why they obtained such tattoos and what they symbolize. In order to assist with such exploration, the next section identifies a number of recognized tattoo motivation theories.
Tattoo Motivation Theories
To determine effective strategies to reduce tattoo bias and counsel tattooed clients, it is important to understand the motivations and theoretical premises of why people get tattoos. This section describes recognized tattoo motivation theories. Recent findings in tattoo research cited within this article highlight the limitations of these theories and prompted us to propose our own, the unencumbered self theory of tattoos, which focuses on sociocultural influences. From this new perspective, we hope counselors will have a clearer understanding of the motivations behind getting a tattoo, which will in turn increase understanding of tattoo culture and what this implies about clients and counseling practice. To illustrate how these theoretical models might be of use in a clinical setting, in the subsequent section we provide a case study in which we discuss, compare, and contrast theories and exemplify the need for a new understanding of tattoo motivation.
Psychodynamic Theory of Tattoo
The first hypothesis for tattooing is rooted in psychodynamic theory. This theory posits that tattoos are an outward manifestation of intrapersonal conflict or unresolved psychological concerns (Grumet, 1983; Karacaoglan, 2012; Lane, 2014). The belief is that permanent skin marking serves as a visible mnemonic that prompts a defense mechanism that helps alleviate the anxiety caused by conflict within the id, ego, and superego. In other words, the symbolism embodied within the marking of the skin iteratively releases blocked psychic energy, causing temporary relief from various difficult symptoms.
Psychodynamic theory is problematic because it fails to address the alternative motivations for getting tattoos, namely, the aforementioned social–cultural perspective. Moreover, Freud’s psychoanalytic approach is rooted in Western civilization’s understanding of internal processes and is therefore heavily influenced by a European, White, male perspective of psychic processes, thus ignoring the effects of oppression and inequality on personal identity, mental health, and behavior. As was indicated in the previous research review, and as we will see in subsequent sections, current tattoo research does not support the notion that tattoos are merely the result of unconscious conflict.
Human Canvas and Upping the Ante Theories of Tattoo
Moving beyond the arguably deficit ideology of the psychodynamic theory of tattoos, Carmen et al. (2012) proposed two evolutionary theories of tattoo motivation that transcend obvious reasons like self-expression and group membership. The first theory, human canvas, argues that it is our innate longing to express the most authentic desires of our psyche through symbolic thought, originally on cave walls and later on our bodies. Their second theory, upping the ante, postulated that with increasing longevity and improved health care, the opportunities for attracting mates are more competitive, and people must devise new ways to stand out to attract mates, much like a peacock spreading its feathers.
The human canvas and upping the ante theories of tattoos are at least to some degree supported by current research (e.g., Wohlrab et al., 2007), and both theories advance our understanding of the motivation behind tattoos beyond psychodynamic theory. Indeed, people spend considerable time and thought choosing their tattoos for personal self-expression (Kaufmann & Armstrong, 2022) and to symbolize cultural traditions, sexual expression, and the love of art (Wohlrab et al., 2007). Although these theories advance tattoo theory, they fail to consider the even deeper meaning which suggests that tattoos are a way to regain bodily control and express displeasure with mandated values imposed by external influences. In essence, it is clear that tattoos are a form of self-expression, potentially to increase personal uniqueness and attractiveness, but this fails to explain what people are hoping to express. Thus, informed by contemporary tattoo research, we propose a new and expanded theory that attempts to explain the rationale behind tattoo acquisition through a wider societal lens.
The Unencumbered Self Theory of Tattoo
The unencumbered self theory of tattoos advances existing tattoo theory and aligns with current counseling trends by postulating that tattoos symbolize the uniquely human desire to transcend norms and laws imposed by external influences such as imperialism. After an exhaustive review of the tattoo literature, it is evident that the motivation to reclaim personal power from oppressive systems is one reason some people get tattoos, and this motivation is not explicitly stated within existing theories. While most closely aligned with the human canvas theory, the unencumbered self theory of tattoos differs in one subtle but essential way. The human canvas theory postulates that tattoos are a general form of self-expression (e.g., hobbies, memorials, identity, individuality). At the same time, the unencumbered self theory of tattoos suggests that specific individuals acquire tattoos as a deliberate assertion of autonomy and a repudiation of arbitrary societal norms. Take, for example, a client of Cherokee heritage who gets a tattoo depicting Cherokee syllabary. The human canvas theory would hold that this tattoo is motivated by the client’s desire to identify with her cultural heritage. The unencumbered self theory of tattoos acknowledges her desire to identify with her cultural heritage, but this desire is motivated by the need to disengage from the oppressive systems that successfully squelched her people’s values for so long.
Evidence supporting the unencumbered self theory of tattoos includes cross-cultural studies examining motivations behind obtaining tattoos (Atkinson, 2002; Khair, 2022; Kloẞ, 2022). Atkinson (2002) reported that Canadian women wore tattoos to challenge societal definitions of femininity, and Khair (2022) found that Middle Eastern women obtained tattoos primarily to express their uniqueness and to indicate ownership of their bodies. Khair (2022) stated, “In fact, women of the Middle East have been struggling to obtain the freedom of their identity due to various restrictive reasons that relate to religion” (p. 3). This sentiment is further supported by Stein (2011) who stated, “My data suggest that—rather than seeing themselves as capitulating to market forces—people think of their decision to get tattoos as an exceptionally deep expression of personal identity, as well as a dramatic declaration of autonomy” (p. 128).
Additionally supporting the cultural motivations behind obtaining tattoos, Kloẞ (2022) identified Hindu women having tattoos that symbolize both oppression from and resistance to patriarchy, colonialism, and orthodox religious beliefs. Relatedly, Stein (2011) stated that the motivation behind tattoos is, at least in part, “a defiance of patriarchal authority” (p. 113). This desire to live unencumbered is also evidenced in research indicating that tattooed people are less likely to be members of religious groups (Laumann & Derick, 2006); are less likely to conform to societal norms, as evidenced by lower scores on personality assessments measuring agreeableness and conscientiousness (Tate & Shelton, 2008); and are considered more authentic and relatable (Zidenberg et al., 2022).
The unencumbered self theory of tattoos also coincides with current research and theoretical advancements in the counseling profession. Integrative approaches, such as narrative, relational, and art therapies, illustrate how tattoos can be used to externalize issues and emotions onto the body and promote self-expression by re-authoring life stories that are freeing and healing (Alter-Muri, 2020; Covington, 2015). Further, there is an increasing interest in Indigenous healing practices and the counseling profession’s embrace of a more collaborative and collective approach to health and wellness. To illustrate how the unencumbered self theory of tattoos advances tattoo theory and serves the counseling profession, we compare and contrast the existing theories in the following case study.
Case Study and Discussion
In this fictional case study, Sage is a 28-year-old, cisgender, queer, able-bodied female whose mother is Eastern Band Cherokee and whose father identifies as Mexican American. Sage upholds many traditional Cherokee customs and regularly attends tribal council meetings as well as powwows where she dances in traditional native attire. Sage has several visible tattoos on her arms and one on the back of her neck, all of which symbolize her Cherokee heritage. She presented to counseling with increasing depression after quitting drugs and alcohol for the past year and reports being unhappy in her job with no meaningful relationships. Sage’s counselor does not have tattoos and identifies as White, female, and a social justice advocate who knows very little about people with tattoos or Cherokee customs.
From the psychodynamic theory of tattoo (Grumet, 1983), Sage’s tattoos would be considered an expression of inner conflict and unmet needs, and the counselor would ask questions hoping to uncover unconscious beliefs that are causing her depression. In this case, the counselor may not even mention her tattoos, but instead view them from a deficit lens indicating a personal problem to resolve.
In both the human canvas and upping the ante evolutionary theories of tattoos (Carmen et al., 2012), Sage’s tattoos could indicate her desire to express her individuality and enhance her attractiveness. With this in mind, the counselor is likely to acknowledge her tattoos and ask about their meaning. However, both theories fail to recognize that Sage’s tattoos may signify deeper underlying issues related to potential oppression and inequality she feels because of her race, ethnicity, and gender.
From the unencumbered self theory of tattoos, Sage’s tattoos could reflect her motivational factors, feelings of alienation, and desire to align her authentic self and heritage. From this perspective, the counselor might explore whether she has experienced discrimination and how the impact of societal marginalization shaped her current sense of self. For example, the counselor may ask, “Have you ever experienced feelings of alienation or disconnect from others, and if so, how do you think your tattoos relate to those experiences?” Another counselor probe could be, “What emotions or thoughts come up when you think about the stories or meanings behind your tattoos?” In addition, the counselor may inquire into cultural healing traditions that help Sage reclaim her authenticity and realign her with her Indigenous heritage. In this instance, the counselor may ask, “Are specific cultural or familial traditions associated with your tattoos, and how do they contribute to your sense of authenticity?” or “Have your tattoos played a role in helping you reconnect with or reclaim aspects of your cultural identity?” Ultimately, through understanding the unencumbered self theory of tattoos, the counselor can better assist Sage by gaining deeper insight into her experiences, her motivations, and the significance of her tattoos within the context of her identity and mental health journey.
In summary, clients’ motivations for tattoos are complex and include explicit explanations, such as self-expression and identity, and potentially implicit motivations, such as increased attractiveness and autonomy. Based upon the tattoo motivation research, we believe the unencumbered self theory of tattoos provides a more comprehensive understanding of the reasons people get tattoos, which appears to be motivated by boldly proclaiming their desire for autonomy and not merely to enhance personal attractiveness. With these findings in mind, the subsequent section describes how counselors, and the counseling profession more broadly, can enhance counseling practice with tattooed clients.
Implications for Counseling
Tattooed clients and counselors will become increasingly common, if not the norm. Consequently, there are clinical, professional, ethical, and societal considerations associated with the increasing popularity of tattoo art. This section addresses what counselors can do to adeptly navigate the increasing prevalence of tattoo culture and better serve their clients.
Counselors must reexamine their potential bias about tattooed clients and recognize that current research suggests they are not more likely to have mental and behavioral problems (e.g., Pajor et al., 2015). In fact, tattoos on a client might indicate their readiness for counseling by showing their strength and desire to break free of parental and societal expectations (e.g., Crompton et al., 2021). However, the number and placement of tattoos may better indicate potential mental health issues (Mortensen et al., 2019). With this in mind, asking clients about their tattoos early in the counseling relationship may help build rapport and provide potentially rich information about the client’s life story. Specifically, if the client’s tattoo is visible, it would be appropriate and possibly helpful to ask about it during intake (Kaufmann & Armstrong, 2022).
To foster genuine rapport and mitigate power imbalances in the therapeutic relationship, it is crucial for counselors to engage in self-reflection, cultivate cultural awareness and humility, and understand the potential cultural significance of tattoos (Day-Vines et al., 2018). Initiating conversations about clients’ tattoos early in counseling can be an effective strategy. Counselors might ask: “Tattoos often have special meanings or stories attached to them. What inspired you to get yours?” This approach demonstrates respect for the client’s personal and cultural narratives, promoting a more equitable and empathetic counseling environment. For instance, inquiring about a client’s neo-Nazi tattoos demonstrates the counselor’s desire to understand all aspects of the client. Despite the offensive nature of the tattoos, questioning could prompt the client to disclose personal experiences such as family addiction, abuse, poverty, insecurity, and fear of losing one’s identity in an increasingly multicultural society. These disclosures might not have emerged otherwise.
Counselors do not necessarily need to cover their tattoos, because they may help increase clients’ perception of the counselor’s relevance (Zidenberg et al., 2022). In fact, the counselor disclosing their tattoos may propel some clients to share more personally relevant information during sessions (Stein, 2011). Depending upon the client, a counselor with tattoos could broach the topic of how their tattoos symbolize their pursuit of authenticity in a society where the values of marginalized populations (e.g., women, non-White, LGBTQ) are too often not recognized, understood, or honored.
This example shows how a counselor could broach the topic of tattoos:
During our sessions, we have been exploring various aspects of identity and self-expression, which has led me to reflect on something personal I would like to share with you. As you may have noticed, I have some tattoos that hold particular significance. I have found that my tattoos remind me of essential experiences and values in my life. I share this with you because I believe it is vital for us to foster an environment of openness and authenticity in our therapeutic relationship. However, I want to emphasize that our sessions are about you and your journey. So, if you have any questions or concerns about my tattoos or anything else, please feel free to share them with me. I am here to create a safe and open space to discuss anything that comes up for you.
Thus, the counselor’s tattoo narrative may offer the client freedom to explore repressed aspects of themselves, which, once discovered, may allow for more self-awareness and appreciation, ultimately resulting in better mental health. Counselors can also simply discuss their tattoos with clients who express curiosity or concern. This approach allows the counselor to provide context and meaning behind their tattoos, potentially fostering a deeper connection and understanding between counselor and client.
However, some clients might be disinclined to continue services with an obviously tattooed counselor. As such, counselors may choose to cover their tattoos during sessions, especially if they anticipate that it may distract or discomfort certain clients. This approach can help maintain a professional appearance and minimize potential barriers to therapy. These kinds of tensions may lead to the strategic use of profile photographs on one’s counseling practice’s website. Depending on their client base and target demographics, counselors may opt for photographs that either prominently display or discreetly conceal their tattoos. Prioritizing the client’s comfort and preferences is essential. Counselors should gauge the client’s reactions and adjust their approach accordingly. In sum, the best advice for counselors with tattoos is to rely on their clinical intuition and discretion when deciding how to approach discussions about personal tattoos with clients. As with any counselor disclosure, discussing personal tattoos should be used intentionally with the client’s best interest in mind.
If a client inquires about the advisability of getting tattoos, it is essential to assist them in thoroughly processing this decision, as with any significant life choice. Be open with clients that biases against tattoos persist, with people of color and women being the most stigmatized. Regrettably, many individuals harbor negative perceptions of tattooed people, particularly regarding visible body art and content that might be deemed offensive. Counselors can ask probing questions about the client’s reasoning for obtaining tattoos, such as, “What does getting this tattoo mean to you, and how do you think it will impact your sense of identity or self-expression?” and “Have you considered any potential long-term implications of getting this tattoo, including how you might feel about it in the future or how it might affect your personal or professional life?”
The intersection of tattoos, mental health, and social justice represents a rich and largely unexplored area of research for counselor educators. As the prevalence of tattoos increases among both clients and counselors, we believe this presents a rich opportunity for personal exploration and the discovery of values and strengths, an area currently underexplored in the counseling profession. Future research on tattoos could examine their presence on counselors and clients, their effect on the therapeutic alliance, personality differences among tattooed individuals, and tattooed people’s likelihood of engaging in advocacy work. To advance dialogue and research in this domain, the Western Carolina University counseling program’s faculty, students, and graduates created the Intersection: Art, Mental Health, and Social Justice magazine (Mock et al., 2021). This publication aimed to enhance dialogue and understanding regarding tattoos. Readers are encouraged to peruse the online magazine to explore personal stories of tattooed counselors.
Conclusion
With the increasing popularity and prevalence of tattoos combined with continued cultural bias, body art is an area that warrants further research and discussion in the counseling profession. In summary, there does not appear to be significant relationship between tattooed people experiencing more mental health problems than nontattooed people. However, there is continued bias against tattooed people, and the reasons for obtaining tattoos are rooted more deeply than merely increasing personal attractiveness. As described in the unencumbered self theory of tattoos, the reemergence of tattoo art may be emblematic of the trends seen throughout the counseling profession to advance the discipline from its focus on intra- and interpersonal theories of health and wellness to include broader sociological perspectives on healing. The reemergence of tattoo art, then, could be an allegory for moving beyond the White, male, heteronormative standards that have traditionally dominated the profession, ushering forth an age of inclusivity where the rich and complex tapestry of all people’s values, traditions, and customs can be known and honored.
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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Russ Curtis, PhD, LCMHC, is a professor at Western Carolina University. Lisen C. Roberts, PhD, is an associate professor at Western Carolina University. Paul Stonehouse, PhD, is an assistant professor at Western Carolina University. Melodie H. Frick, PhD, NCC, ACS, LPC-S, is a professor at Western Carolina University. Correspondence may be addressed to Russ Curtis, Western Carolina University, 28 Schenck Parkway, Office 214, Asheville, NC 28803, curtis@wcu.edu.
May 22, 2024 | Volume 14 - Issue 1
Rebekah Cole, Christine Ward, Taqueena Quintana, Elizabeth Burgin
Military spouses face many challenges as a result of the military lifestyle. Much focus has been placed on enhancing the resilience of military spouses by both the military and civilian communities. However, no research currently exists regarding spouses’ perceptions of their resilience or how they define resilience for themselves and their community. This qualitative study explored the perceptions of eight military spouses regarding their resilience through individual semi-structured interviews. The following themes emerged: 1) shaped by service member and mission priority; 2) challenges within the military lifestyle; 3) outside expectations of spouse resilience; 4) sense of responsibility for family’s resilience; 5) individual resilience; and 6) collective resilience. We discuss ways military leadership and the counseling profession can best understand and enhance the resilience of military spouses.
Keywords: military spouses, resilience, military lifestyle, perceptions, counseling
Because of the unique stressors associated with the military lifestyle, military spouses are at an increased risk for poor mental health (Donoho et al., 2018; Mailey et al., 2018; Numbers & Bruneau, 2017). They may experience mental health concerns, such as anxiety and depression, due to a number of reasons, including separation from their deployed service member, loss of support networks after a relocation, or issues with adjusting to the uncertain and frequent changes of the military (Cole et al., 2021). Additional concerns that arise, such as employment, marital, and financial issues, can also negatively affect the military spouse’s mental health (Cole et al., 2021; Mailey et al., 2018). Dorvil (2017) reported that 51% of active-duty spouses experience more stress than normal. Furthermore, 25% of military spouses meet the criteria for generalized anxiety disorder (Blue Star Families [BSF], 2021). Depression in military spouses is also higher than the rate found within the general population (Verdeli et al., 2011). As a military spouse casts aside their own personal needs to support their service member, stressors may continue to increase, which can contribute to the rise of mental health needs of military spouses (Moustafa et al., 2020).
Resilience and Military Spouses
Nature of Resilience
Given the challenges inherent in the military lifestyle and the associated mental health risks, military spouse resilience is essential. Resilience is a complex and multifaceted construct, significant to researchers, practitioners, and policymakers across numerous disciplines, including mental health and military science. The American Psychological Association (2020) defined resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress” (para. 4). Within the military community, resilience has been defined as the ability to withstand, recover, and grow in the face of stressors and changing demands (Meadows et al., 2015). Importantly, determinants of resilience include the interaction of biological, psychological, social, and cultural factors in response to stressors (Southwick et al., 2014). In addition to these salient variables embedded in resilience science, resilience may be operationalized as a trait (e.g., optimism), process (e.g., adaptability in changing conditions), or outcome (e.g., mental health diagnosis, post-traumatic growth; Southwick et al., 2014).
Resilience may also vary on a continuum across domains of functioning (Pietrzak & Southwick, 2011) and change as a function of development and the interaction of systems (Masten, 2014). Accordingly, a definition and operationalization of resilience may vary by population and context (Panter-Brick, 2014). During the post-9/11 era, the resilience of service members and their families received significant attention from stakeholders, including the Department of Defense (DoD) and National Academies of Sciences, Engineering, and Medicine (NASEM), both of which expressed a commitment to conducting research and establishing programming to enhance service member and military family resilience, resulting in increased awareness of the importance of service member and family resilience throughout the military community (NASEM, 2019).
Military Family Resilience
Though military families share the characteristics and challenges of their civilian counterparts, they additionally experience the demanding, high-risk nature of military duties; frequent separation and relocation; and caregiving for injured, ill, and wounded service members and veterans (Joining Forces Interagency Policy Committee, 2021). In recognition of the constellation of military-connected experiences military families face, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) commissioned a review of family resilience research and relevant DoD policies to inform a definition of resilience for appropriate application to military spouses and children (Meadows et al., 2015). Meadows and colleagues (2015) proposed family resilience may be best defined as “the ability of a family to respond positively to an adverse situation and emerge from that situation feeling strengthened, more resourceful, and more confident than its prior state” (see Simon et al., 2005, for a further exploration of family resilience). Further, Meadows and colleagues identified two groups of policies delineated at the Joint Chiefs of Staff or DoD levels, or within individual branches of the military: 1) existing programs modified to augment resilience or family readiness, and 2) new programs developed to target family resilience. Programs established by these policies support access to mental health services (e.g., DoD Instruction [DoDI] 6490.06); parenting education (e.g., New Parent Support Program, DoDI 6400.05); child welfare (e.g., Family Advocacy Program, DoD Directive 6400.1); and myriad physical, psychological, social, and spiritual resources. The well-being of military families represents a critical mission for the DoD, extending beyond provision and access for families to meet their basic needs to individual service member and unit readiness, and the performance, recruitment, and retention of military personnel (NASEM, 2019).
Military Spouse Resilience
Though service member and family resilience are critical for accomplishing the DoD’s mission, focusing on the unique nature of military spouse resilience is key for understanding and supporting this population’s resilience. Counseling, psychology, sociology, and military medical professional research related to military spouse resilience has focused primarily on characteristics associated with resilience. In a study by Sinclair et al. (2019), 333 spouse participants completed a survey regarding their resilience, mental health, and well-being. The results revealed that spouses who had children, were a non-minority, had social support, had less work–family conflict, and had a partner with better mental health were more resilient. Another survey study examined the characteristics associated with resilience in Special Operations Forces military spouses, determining that community support and support from the service member was essential for spouse resilience (Richer et al., 2022). A study conducted within the communication field also explored spouses’ communicative construction of resilience during deployments. Qualitative data analysis of interviews with 24 spouses indicated how spouses use communication to reconcile their contradictory realities, which increases their resilience (Villagran et al., 2013). This resilience has also been found to be a protective factor against depression and substance abuse during military deployments (Erbes et al., 2017). Finally, a survey study of Army spouses (N = 3,036) determined that spouses who were less resilient were at higher risk for mental health diagnoses (Sullivan et al., 2021). While these studies explored the nature of resilience demonstrated by military spouses, our searches in JSTOR, PubMed, ERIC, PsycINFO, and Google Scholar did not reveal any studies regarding spouses’ perceptions of their own resilience or how they define this resilience for themselves and their community. Our study fills that research gap by exploring active-duty spouses’ perceptions and definitions of resilience.
Methods
The purpose of this qualitative study was to explore the perceptions of active-duty spouses regarding their resilience. This study was guided by the following research questions: 1) What are military spouses’ perceptions of their own resilience? and 2) How do military spouses define “resilience?” Phenomenology seeks to present a certain phenomenon in its most authentic form (Moustakas, 1994). In order to most authentically and openly describe our participants’ experiences, we chose a qualitative transcendental phenomenological approach to frame our study. This tradition of qualitative research focuses on portraying a genuine representation of the participants’ perceptions and experiences. However, the distinct feature of transcendental phenomenology is its first step, which involves the researchers recognizing and bracketing their biases so they can analyze the data without any interference (Moerer-Urdahl & Creswell, 2004). We selected this design because each of our research team members were military spouses. We therefore recognized the need to mitigate our biases in order to give a true representation of the participants’ perceptions, free from our own preconceived notions.
Participants
The participants in this study were selected based on their status as active-duty military spouses and their willingness to participate in the study. There were no other inclusion or exclusion criteria for the participants in this study. After gaining IRB approval, we used convenience sampling to recruit eight participants. In qualitative research, convenience sampling is used to recruit participants who are closely accessible to the researchers (Andrade, 2021). Our research team emailed participants that we knew through living, working, and volunteering on military bases throughout the United States and at overseas duty stations who fit the active-duty military spouse criteria for this study and asked them if they were willing to participate in the study. Once the participants expressed interest, they were provided with an information sheet regarding the study’s purpose and the nature of their involvement in the study. Participant demographics are included in Table 1. All of the participants were female and all were between the ages of 30–40. Four branches of the U.S. military, including Army, Navy, Air Force, and Marine Corps, were represented in the sample. No reservist, Coast Guard, or Space Force military spouses participated in our study. Five of our participants were White and three were Black. Their tenure as military spouses ranged from 4 years to 17 years. Five of the spouses were married to a military officer, while three of the participants were married to an enlisted service member. After interviewing these eight participants, our research team met and determined that because of the distinct common patterns we found across each of the participants’ transcripts, we had reached saturation and did not need to recruit any additional participants for our study (Saunders et al., 2018).
Table 1
Participant Demographics
| Participant |
Age |
Ethnicity |
Gender |
Branch |
Spouse’s Rank |
Years as a Spouse |
| 1 |
33 |
Black |
Female |
Air Force |
Enlisted |
4 |
| 2 |
36 |
Black |
Female |
Navy |
Enlisted |
17 |
| 3 |
31 |
White |
Female |
Army |
Officer |
7 |
| 4 |
34 |
Black |
Female |
Navy |
Enlisted |
14 |
| 5 |
36 |
White |
Female |
Marine Corps |
Officer |
12 |
| 6 |
35 |
White |
Female |
Marine Corps |
Officer |
14 |
| 7 |
40 |
White |
Female |
Navy |
Officer |
16 |
| 8 |
34 |
White |
Female |
Navy |
Officer |
10 |
Data Collection
Our research team first developed the interview protocol for the study based on a thorough review of the literature regarding resiliency within military culture as well as the challenges of the military lifestyle for military spouses. Our research team members interviewed each of the participants for 1–2 hours. These semi-structured interviews were audio recorded and transcribed verbatim by an automated transcription service. The interview questions were open-ended and focused on the spouses’ definitions of resilience and their perceptions of their resilience within the military lifestyle and culture (see Appendix for interview protocol). In addition, probing questions such as “Can you explain that a bit more?” or “Can you give any examples of what you mean by that?” were used to gather more in-depth data throughout the interviews.
Data Analysis
We followed the steps of the transcendental phenomenological data analysis process to analyze our study’s results (Moerer-Urdahl, 2004). First, each member of our research team engaged in epoche, in which we bracketed our biases as military spouses so that our own thoughts, feelings, perceptions, and experiences did not influence our interpretation of our participants’ experiences. The next step in the process was horizontalization. During this step, each member of our research team read through the interview transcripts and noted significant statements throughout so we could better understand how the participants perceived, understood, and experienced resilience. Next, we met as a research team to discuss these significant statements and organize them into themes (Moustakas, 1994). Our research team then developed textual and structural descriptions of the themes, describing not only a list of the participants’ perceptions, but also an in-depth analysis of what their perceptions of resilience entailed and how they have experienced it throughout their tenure as military spouses (Moerer-Urdal, 2004; Moustakas, 1994). We then constructed a comprehensive description of the participants’ perceptions of resilience, encapsulating the “essence of the experience” (Moerer-Urdal, 2004, p. 31).
Research Team and Strategies to Increase Trustworthiness
Our research team consisted of four university faculty members, all of whom possessed extensive experience in conducting qualitative research. Three of our research team members possess PhDs in counseling and one research team member possesses an EdD in counseling. All team members had extensive experience conducting research with military-connected communities. In addition, all of our research team members were active-duty military spouses, with years of experience as a military spouse ranging from 1–23 years.
We used several strategies to increase the credibility of our results. First, the use of an experienced research team to collectively analyze the data resulted in diverse perspectives on the emerging themes of the study. However, because each member of our research team was a military spouse, we recognized the need to bracket our own experiences and biases so that they did not interfere with our interpretation of the data. Each team member took notes on their individual biases, and our research team discussed these biases when interpreting themes. Biases held by research team members included a predisposition to believe that spouses of special warfare service members endured greater stressors and were better supported by their military communities; a belief that spouses of higher-ranking service members possessed greater knowledge of and access to resources to support social, behavioral, and mental health needs; and personal experience within the military spouse community. These biases were challenged throughout the research process by each member of the team. As each theme was identified, the team referenced individual transcripts to ensure that the interpretation was justified. We found that our biases were rightfully challenged.
Additionally, to avoid leading questions, our research team made the conscious decision not to define resilience as part of the interview and follow-up process. The team wanted to derive an organic definition of spouse resilience that was not clouded by a formal definition. In addition, we used member checking, in which we emailed the interview transcripts to the participants and asked them to verify the data. The participants responded to our request with minimal change requests related to grammatical errors in the transcriptions and validated our data. Several offered additional insight related to their definition of resilience, which was included in our data analysis.
Results
The following themes emerged from our data: 1) shaped by service member and mission priority; 2) challenges within the military lifestyle; 3) outside expectations of spouse resilience; 4) sense of responsibility for family’s resilience; 5) individual resilience; and 6) collective resilience.
Theme 1: Shaped by Service Member and Mission Priority
Military/Service Member Definition
When discussing their definition of resiliency, the spouses first considered what resiliency meant for their active-duty spouse. The participants varied in their perceptions of what resilience meant for their active-duty service member, though all defined resilience as an active process of adapting or persevering when faced with adversity, rather than a personal trait or characteristic the service member possesses. Participant 3 noted that, for their spouse, resilience was “the ability to adapt to changes that are beyond your control . . . adapting to situations in an optimistic and positive way.” Participant 6 stated that resilience for their spouse meant an “ability to bounce back from a hardship.” One participant asked their spouse to comment specifically about their definition and provided the following definition in a follow-up with the interviewer: “Resilience is how you persevere in difficult circumstances. It’s not about how hard you fall, but how quick you can get back up from being knocked down” (Participant 2 [P2]).
Some participants cited specific notions of resilience that are embedded in the service members’ military community. One Navy spouse remarked that resilience, to their spouse, meant “Don’t give up the ship” (P8). Another Navy spouse mentioned that for their spouse, resilience was “knowing how to weather the storm” (P7). Yet another spouse noted that resilience “the Marine Corps way” meant their service member must “do their job” (P4). Other participants noted that the root of resilience for the military service member stems from a place of selfless service. Participant 8 commented that the resiliency of their spouse was “more about the man standing next to me, the family I’m fighting for at home, the country I’m fighting for at home, than about their own personal needs.”
Adapting, Overcoming, and Persevering
Like their active-duty members, spouses indicated that resilience was about adapting, overcoming, and persevering in the face of obstacles. Resilience to one spouse was “being able to rebound or to overcome an obstacle” (P1); to another, resilience meant they must “be flexible, adapt with whatever, overcome whatever it is that you’re going through” (P2). Spouses noted that resilience was not a one-time event. Instead, spouses suggested that their own resilience stemmed from continually persevering. Participant 6 stated that for them, resilience meant not just “going through something difficult and making it out on the other side,” but that they then had to “keep pushing forward.” One participant indicated that their personal definition of resilience and the notion to persevere stemmed directly from their spouse: “I’ve almost kind of adopted a bit of my husband’s thought process, I guess. You just keep going to get things done” (P8).
Mindset
Our participants indicated that resilience was a mindset that one must choose and that when faced with difficulties, they chose to focus on gratitude, positivity, and growth. For example, Participant 8 stated that, although they had faced and would continue to face challenging and stressful experiences as a result of being a military spouse, they believed that “whatever may come, we’ve been very blessed in our life and we should always be thankful for the life that we have.” Another participant noted that for them, overcoming and persevering meant adopting an optimistic attitude. Specifically, the spouse stated, “sometimes you just have to kinda look at the bright side of things, and you have to find the things that work for you at each place” (P5). One participant drew resilience from a growth mindset:
I think it [resilience] is really a mindset switch. I think it’s changing from “oh this is happening to me, how horrid” to like “how can I take this horrid situation and turn it into something good?” And I think that is a big mindset switch. (P7)
Resilience Variations
Walsh (2012) described risk and resilience as a process of balancing risk and protective factors over the life span. Participants in our study expanded on that idea by suggesting that they reacted to situational challenges along a continuum:
I think what I’m saying is there’s different levels of resilience, like sometimes you have to tap into that different part of yourself. Sometimes you have to let it go and just accept the things that come, and sometimes you just gotta pick yourself up and keep on trucking. (P8)
Likewise, Participant 3 suggested that resilience takes different forms depending on the situation:
Sometimes resiliency just means like surviving day to day and other times, it means figuring out how to continue with your passions to the best of your ability while also supporting your family and your [service member spouse]. I think it’s just super unique to every situation. (P3)
Our participants also recognized that their understanding of resilience was often focused on the here and now of their situation but that their reactions to stressors had long-term effects. One participant indicated that resilience is a learning process and recognized that the stressors they overcome now prepare them to address stressors they will face in the future: “I think being able to come out of extremely, extremely stressful situations, be able to come out on the other side and [know] I’m okay and I survived this, and now I’m kind of better prepared for next time” (P6). Participant 3 wondered about the long-term ramifications of resilience in the face of prolonged adversity, stating “I may be resilient right now in the moment, but in the long term, like, how will this affect me?”
Individualized
Finally, participants defined resilience as an individualized process, stating things such as “everybody has their own unique ways of being resilient, and I think that they do what works best for their families” (P7) and “my resiliency may look different than someone else’s resiliency” (P2). One participant elaborated on this individualized approach to resilience by recognizing that each person has different risk factors that affect their response to stressors, thus affecting the way each person demonstrates resilience. This participant stated that, when viewing resilience among military spouses as a whole, it is important to
take into consideration somebody’s upbringing and the baggage that they bring into this life. We don’t know what people have gone through as kids, and that I think would have a big impact on whether or not someone can be resilient, so I don’t think it’s a one-size-fits-all. (P6)
Theme 2: Challenges Within the Military Lifestyle
Lack of Control
The spouses described the common challenges of the military lifestyle to their resilience. First, they discussed the stress of the feeling of a lack of control in their lives. One participant described how she
just found out yesterday that my husband was getting deployed and he’s leaving Sunday. And I keep hearing people say, “You have to be resilient. You’re gonna be okay!” You’re resilient, but right now, what it feels like is how much can you endure for the sake of the mission? (P1)
Another echoed this sentiment: “I have no control if the Navy says they’re going to deploy my husband. There’s nothing I can do to change that” (P8).
Constant Changes
Another common challenge mentioned among all of the participants was the constant changes they experience in their lives, including moving, career changes, and changes within their family dynamics. Because they move every few years, the spouses described how they are constantly separated from their support systems: “Even though you meet these great people, you don’t get to stay with them . . . and you’re generally not near your family, which is very hard” (P5). Another described how “Once I have started on something and I’m like, ‘This is it, we gon’ be here for a while,’ then my husband is like ‘nope. Military said we got to shift and move again’”(P2).
These constant changes resulted in career struggles for the spouses. One asked, “How can I get this [job] if I’m never at one place for long? . . . How do I uproot everything that I know or everything that I am doing to follow my service member?” (P2). Another described how “moving, changing jobs, not being able to have a secure profession, you do it because you have to . . . but that doesn’t mean that there’s not a whole lot of emotional and mental load that goes with it” (P3).
Another challenge for military spouses was constantly changing family dynamics. One described the difficulty in constantly changing work schedules: “We have to kind of get into this routine without him and then when he comes back, because it’s different while he’s away. We gotta kind of try to fit him back into our routine when he gets back” (P4). Another discussed the challenge of transitioning to being the sole caregiver during a deployment: “If I go down with COVID, what am I going to do? Because, like, I was literally IT. No one is going to want to take my kids. . . . That was the first time I ever felt, like, fearful” (P7).
Mission Priority
In addition to constant change, the spouses also mentioned the challenges of the military’s clear prioritization of the mission above military members and their families: “If something is going on at home, we’re going to take care of our active person first and worry about your family later” (P2). The participants described how this focus on the mission is so intense that it affects service members physically, which increases the burden on military spouses to care for them: “My husband’s health suffers because the mission is most important to him” (P1).
Theme 3: Outside Expectations of Spouse Resilience
Expectation to “Suck It Up”
The spouses described others’ expectations for their resilience. First, they described the military’s expectation that they “suck it up.” One described how “you have a lot of the ‘suck-it-up’ mentality, and I would say when you have the leaders who kind of fall under that, whether it’s seeking the mental health treatment or having stigmas with that” (P6). Another explained that “there’s so much focus and emphasis on just being resilient and sucking it up” so there is often a mindset of “‘Oh well, military spouses are resilient so they signed up for this, they know what it takes and they just have to get over it’” (P3). Another spouse described how “they put so much pressure on you to be like, just make it work, that you’ve gotta figure out the way to make yourself happy, and that’s hard to do” (P5). Participant 7 summed up the military spouse mentality as a whole: “You toughen up and you make it work. You know?”
The participants felt their overall resilience would be enhanced if individuals outside the military community better understood the challenges faced by military families. One participant felt the “suck it up” mentality stemmed less from the military community itself and more from outside communities who might not understand the struggles of military family life: “So when . . . you’re going through another stress of a PCS [permanent change of station], you can’t find a house, they say, well, at least you get a house allowance, at least you get free health care” (P6). Participant 3 expanded on this idea by stating, “I just honestly think that a greater understanding of what sacrifices that military spouses make . . . would increase resiliency, because there’s just so much lack of understanding what it actually entails.” Lastly, one participant mentioned a sentiment they frequently hear from others in a civilian community, expressing that it was frustrating when friends outside the military told her, “I don’t know how you do it,” to which the participant responded, “I don’t know, you just do it!”
Pressure to Be Resilient
The spouses also expressed frustration at others’ misperceptions of the expectation that they and their families demonstrate resilience: “When we call military spouses or children resilient, it just seems like a cop out and relinquishes any type of burden . . . or feeling of guilt about a situation that may cause emotional or mental damage” (P3). Another participant echoed this frustration: “Sometimes I don’t feel like I’m being resilient. Sometimes I feel like I’m just doing what needs to be done because that’s what needs to be done” (P8). Another participant described how her friends
call me Superwoman because I have all these different things going on and I always seem like I got it together. . . . It’s like saying to me that I have to keep going, no matter what, and I think people should be able to just feel defeated sometimes. Or be able to say “that was just too much for me” or “I don’t really feel like being resilient today, I kind of want to lay in bed and just be upset or sad.” (P4)
Given these expectations, one spouse pointed out the danger of expecting military children to consistently demonstrate resilience:
It’s so easy for everyone to say that military kids are always so resilient and sometimes they’re not. Sometimes they are stressed out. They are feeling the crushing weight. They feel sad but everyone keeps telling them that they’re resilient. So it almost makes it seem like . . . they aren’t allowed to feel those hard things or talk about those things or act on those feelings and emotions. (P8)
One spouse proposed a solution to these misperceptions, emphasizing that resilience is unique for military spouses and should be defined to accurately reflect the way they uniquely overcome challenges:
I think it’s important for military spouses to reappropriate that term [resilience] so that it is not weaponized, and I would like to see some sort of guidance as to how we can be resilient but in a way that positively impacts our mental health and physical health and not having to endure all of the things and all of the frustration and uncertainty that comes with the onset of having to be resilient. (P1)
Theme 4: Sense of Responsibility for Family’s Resilience
With their partners focused on the mission, the spouses described their sense of responsibility to maintain their resilience so they can care for their children in the absence of their active-duty spouse: “We have our husband or our spouses gone so much, we need to be a solid parent at home for our kiddos or our family” (P7). Participant 4 likewise described how “I kind of see myself as holding down the fort, you know, because when my husband is not home it is just me and the kids.” Another explained how “I have three little ones that’s looking up to me and I can’t slip away, depressed, because daddy’s not home” (P2). In the end, the spouses defined resilience as an obligation to their families. Participant 3 described that “I have to be that way for my children.” Participant 4 added that “I think that’s what resilience is like, knowing that you kind of have to carry the load, you know, for your whole family to try to keep us afloat.”
The participants described how this resilience is especially obligatory when the active-duty spouse is unable to be resilient:
I’m kind of taking the lead with our kids . . . but I’ve also kind of had to pour into my husband, you know, because he has those times you know where things are really, really hard for him. I’ve also been like his counselor and his doctor sometimes. (P4)
Theme 5: Individual Resilience
In response to being unable to control many aspects of the military lifestyle, most of the spouses described how they have become independent in order to withstand the constantly changing variables within the military lifestyle. One described being “pretty independent, and I think that helps a lot because I don’t rely on my spouse to do all these things I do” (P5). Another described how being independent resulted in self-confidence and resilience:
You gotta figure out how to do all of it just because you can’t ever rely on the spouse being able to help. But I think being able to come out of extremely, extremely stressful situations, be able to come out on the other side and say “I’m okay, and I survived this, and now I’m kind of better prepared for next time.” (P6)
Another spouse described how maintaining an independent identity was key to separating herself from the stressors of the military lifestyle: “That’s a really important part of being a military spouse. It doesn’t have to be a job specifically, but just something that you can be your own person separate from your husband or your spouse’s job” (P8).
The spouses also described the importance of taking care of themselves physically and mentally in order to maintain their resilience. Many described exercise as key to their mental health and wellness: “My biggest coping mechanism is exercise. I’ve found that no matter where I go, I can exercise” (P5). Another spouse described how she “tried to find a kickball team every place we’ve been to since Okinawa because I figured out it’s a stress relief” (P6). Participant 7 echoed that “working out . . . just helps me. It lowers my stress.” One spouse explained how she defaults to exercise when facing the challenges of the military lifestyle because she knows her “ability to recover quickly is directly tied to the way in which I care for myself” (P1).
Theme 6: Collective Resilience
The participants described their reliance on the collective military spouse community for their survival. One spouse, for example, described a connection with other military spouses as the difference between “doing well and barely surviving” (P6). Another spouse described her reliance on the military spouse community: “Community is what it’s all about. I can’t get through anything without community” (P7). Another spouse echoed this survival mechanism: “This is a beautiful community. It’s an amazing place . . . we all get each other. So I think there are times where it’s really hard . . . but we survive, we get through it. We’re resilient. We got the grit” (P7). Participant 1 explained exactly how the military spouse community offers this support to help spouses survive the challenges of the military lifestyle: “When time calls for it, I think, collectively, we bring our resources together to help pull other military spouses up and try to just forewarn them about what the obstacles are and what may have worked for our family” (P1).
The military spouses also described the comfort they found in other military spouses’ understanding of the challenges they face: “I think the most important part and coping is finding your community, so making sure you’re surrounding yourself with women who are going through similar experiences, or who have gone through similar experiences and similar life stages” (P3).
In the midst of this supportive community, the spouses discussed how they actively seek to comfort each other: “You’re not the only one who’s in it who’s having this issue, I understand that you’ll get through this, that we know we’ve been there, we understand how it goes” (P5). This outreach seemed to be especially helpful from spouses who were more experienced with the military lifestyle: “Having that senior spouse example has been so good. . . . She’s always been somebody who said, ‘Hey, I’ve been through a lot. If you ever have any questions, I’m always here for you’” (P8).
In addition to relying on other spouses for their own wellness and resilience, the spouses expressed pride in their ability to contribute to the military spouse community. One described how “I feel like I am a better team player. I feel like I’m more committed to helping others than I have in the past because I know that others will do the same for me” (P7). The participants also described increased self-growth as a result of being a part of a community: “I really don’t think I would have allowed myself to receive help if I hadn’t been part of this phenomenal community that is constantly supporting each other” (P7). Participant 5 echoed this sentiment: “Learning to get that help from other people is something that I feel like you have to kind of get when you are a military spouse because, otherwise, you’re going to have to do everything and you don’t have to.”
Finally, our participants frequently indicated that they felt a “sense of pride” (P7), “connection” (P4), or “camaraderie” (P8) from belonging to a group of military spouses who understood their unique situation. When asked how the military could enhance resilience for military spouses, participants commonly indicated that peer support and fostering connections with senior spouses should be a priority for military commands. One participant noted that their ability to be resilient in difficult times was related to the “opportunities” they had “to connect with other people who are going through similar stuff and who are a part of the same small community” and recommended that the military facilitate more opportunities to connect (P7). Another participant suggested that military commands should “have someone that [the spouse] can talk to” that would “help them to understand the military life whether you are a new spouse or a seasoned spouse” (P2).
Discussion
The purpose of this study was to explore military spouses’ perceptions of their resilience and the ways in which they define resilience for their community. Our study’s results indicate that spouses’ definitions of resilience are currently shaped by service member and mission priority. Our participants also described how they often felt burdened by outside expectations of their resilience as well as by a sense of responsibility for their family’s resilience. Overall, the spouses relied on themselves and the military spouse community to overcome the challenges they faced. Participants expressed a desire for resources aimed specifically at enhancing spouse resilience and more awareness about resilience resources already in place throughout the military.
While past research has examined resilience factors in spouses such as communication skills, social support, and spousal support (Erbes et al., 2017; Richer et al., 2022; Sinclair et al., 2019; Villagran et al., 2013), our study provided new insight into military spouses’ perspectives of their resiliency. This revelation of the spouses’ worldview aids our understanding of ways to best support spouses and areas to focus on to support their resilience. Our participants’ definitions of their resilience were shaped by their relationship with their service member and the influence of the military’s mission. In addition, while past research has indicated that the military lifestyle and culture is challenging for spouses to navigate (Cole et al., 2021; DaLomba et al., 2021; Donoho et al., 2018; Mailey et al. 2018), our participants’ description of their feelings of responsibility for their family’s well-being reveals the added burden that military spouses face as they help their families navigate the military lifestyle. Finally, our participants confirmed that resiliency should be viewed as a variation and is unique to each individual (Pietrzak & Southwick, 2011). As outlined in the professional literature (Masten, 2014; Southwick et al., 2014), the participants confirmed the dynamic nature of resiliency, recognizing that sometimes they felt more resilient than at other times.
In the midst of these challenges, our participants emphasized that the military spouse community serves as a protective factor and a source of their resilience against mental health challenges. This perception of the military spouse community aligns with previous research highlighting the supportive role that spouses play for each other, so much so that it is a protective factor against suicide (Cole et al., 2021). Therefore, military leadership and the counseling community might focus on enhancing this community and connecting spouses with one another—especially more seasoned spouses with newer spouses. In addition, because military-sponsored resilience programs are often targeted to better support service member outcomes, community providers might find ways to focus on supporting the spouses and helping them to overcome the challenges they face in their daily lives.
Finally, the participants discussed how they overcame the challenges of the military lifestyle, including constant moving, deployments, and overall uncertainty, through their own individual and collective resilience. These lifestyle challenges that the participants described correspond to career struggles and shifting family dynamics that cause ongoing stress to the military spouse, both of which have been previously documented in the professional literature (Borah & Fina, 2017; Cole et al., 2021; DaLomba et al., 2021; Donoho et al., 2018; Mailey et al., 2018; Numbers & Bruneau, 2017). Currently, since the withdrawal of troops from Afghanistan, the United States is experiencing peacetime, whereas the nature of future conflicts is uncertain (Marsh & Hampton, 2022). Enhancing the resiliency of military spouses and finding solutions to ongoing stressors is key during this time of peace so that spouses are ready and able to face the stressors of future, potentially large-scale wars (Sefidan et al., 2021).
Implications for Counselors
Professional counselors are called to be trained and ready to meet the unique needs of military spouses, especially in understanding the nature of military culture and its impact on spouse mental health and well-being and enhancing spouse resilience in times of adversity (Cole, 2014). Our study echoes the continued struggles of military spouses described in the professional literature (Cole et al., 2021; Lewy et al., 2014; Runge et al., 2014), suggesting that new and innovative ways of understanding and approaching military spouse resilience is needed within the counseling community. For example, counselors might encourage spouses to explore how their resilience is shaped by the military community in order to increase self-awareness and understanding. They might also help spouses develop their independence and sense of self-efficacy while simultaneously seeking collective support within the military community. Counselors can help spouses examine their social support and help them develop their social skills so they can connect with others around them. Counselors should also help military spouses unpack their perceptions of outsiders’ expectations of their resiliency. Encouraging spouses to reflect on others’ expectations, and the ways in which these expectations impact their sense of well-being, may help define resilience for themselves and capitalize on their unique resiliencies during challenging times. Ultimately, because the military culture is so unique, counselors should seek out professional development so they can better understand how to help military spouses navigate this culture and enhance their resilience. When working with military spouses, professional counselors might explore spouses’ feelings of responsibility for their family members’ health and well-being that were described in our results. In addition, counselors can equip spouses with supportive mental health resources for their family members so they do not feel as if they need to care for them on their own. School counselors, in particular, can provide support for military-connected students at school and can connect military families with resources within both the civilian and military communities to support their mental health and resilience (Cole, 2017; Quintana & Cole, 2021).
Our participants revealed that often the expectation of resilience is burdensome for spouses, which serves as a contradiction to its purposes. Counselors are called to acknowledge the challenges of the military lifestyle and provide support for navigating these challenges, rather than expecting spouses to face these hurdles alone. In addition, counselors might focus on more holistic manifestations of resilience, recognizing that some spouses can be resilient, yet still struggle. Approaching spouses from a strengths-based perspective, rather than from a deficit perspective, can be empowering within the counseling relationship (Smith, 2006).
Limitations
Our recruitment strategy limited our sample size as we only sought participants that we knew through our military spouse networks. In addition, our sample lacked gender diversity, with all of the participants being female. Approximately 91% of active-duty service member spouses are female (DoD, 2022). However, the lack of male participants in the present study is a limitation, and the experience of male spouses is undoubtedly unique and worth exploring in greater depth. Research suggests that stressors and characteristics of resilience transcend gender categories (NASEM, 2019).
Finally, in qualitative research, the researcher’s biases may impact their interpretation of the data. As military spouses, our own experiences may have impacted the way in which we described our participants’ experiences. We took several steps to mitigate these biases, including intentionally bracketing them and engaging in peer debriefing throughout the research process.
Implications for Future Research
The participants in our study described a need for resources and programs geared specifically toward military spouses. Future research might determine how to best develop and implement these programs that will help to enhance spouse resilience. Key areas of focus may be ways to leverage the military spouse community and enhance spouse sense of self, which were two protective factors that emerged from our data. In addition, existing resilience programs within the military that are currently aimed at the active-duty population should undergo a program evaluation to determine their effectiveness with military spouses.
As a follow-up to our qualitative research, future quantitative research studies should address limitations noted previously. Specifically, future research should target a larger sample size and broader demographic of military spouses to further explore their understanding and definition of resilience. This larger and more diverse sample size would allow for greater generalizability and would assist with advocacy within the military. Finally, future qualitative research might explore the perceptions of male spouses, in particular, in order to determine their perception of resiliency and any unique areas of needed support.
Conclusion
Military spouses face a wide range of challenges as a result of the military lifestyle. They are expected to be resilient so as to overcome these challenges. However, our study reveals the often burdensome impact of these expectations on military spouses. Our results also illuminate how spouses uniquely conceptualize their own resilience, recognizing the resilience continuum and focusing on the positive impact of their protective community. Overall, the spouses took pride in themselves and their communities for their ability to overcome obstacles. These revelations are key for both the military and the counseling profession in their work to support military spouses wherever they are on this continuum and enhance their community, which is key to their well-being.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript. The opinions and assertions
expressed herein are those of the authors and
do not reflect the official policy or position of
the Uniformed Services University of the Health
Sciences or the Department of Defense.
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Rebekah Cole, PhD, MEd, NCC, LPC, is a research associate professor at the Uniformed Services University. Christine Ward, PhD, is an associate professor at Walsh University. Taqueena Quintana, EdD, NCC, ACS, BC-TMH, LPC, is an associate professor at Antioch University. Elizabeth Burgin, PhD, NCC, LPC, RPT, CCCPTS, is an assistant professor and program coordinator of the Military and Veterans Counseling program at William & Mary. Correspondence may be addressed to Rebekah Cole, rebekah.cole@usuhs.edu.
Appendix
Interview Protocol
- Tell me a little about your identity as a military spouse?
- What have been some of your rewarding experiences as a military spouse?
- What have been some of your stressful experiences as a military spouse?
- How have you coped with the more stressful experiences as a military spouse?
- How would you describe the military’s definition of “resilience?”
- What does the term “resilience” mean to you?
- What does the term “resilience” mean for your military partner/family?
- How would you describe the resilience of military spouses?
- In what ways have you, personally, been resilient as a military spouse?
- What would enhance the resilience of military spouses and their families, from your perspective?
- How, if at all, has your military experience enhanced your resilience?
- How, if at all, has the military’s focus on resilience presented you with challenges during your military spouse experiences?
- How, if at all, can resilience be a negative way to describe military spouses/families?
- Is there anything else about military resilience that is important to you that I did not ask about?
Jan 17, 2024 | Volume 13 - Issue 4
Claudia G. Interiano-Shiverdecker, Devon E. Romero, Katherine E. McVay, Emily Satel, Kendra Smith
In this transcendental phenomenological study, we interviewed 10 counselors who have clinical experience working with sex trafficking survivors. Through in-depth individual interviews, participants discussed their lived experiences providing counseling to this population. Our analysis revealed four primary themes: (a) counselor knowledge: “learning curve,” (b) counselor skills: “creating a safe space to dive into work,” (c) counselor attitudes: “being able to listen to the client’s story,” and (d) counselor action: “more than just a counselor.” The findings indicated that counselors working with sex trafficking survivors needed to understand and address the different aspects of trauma. Our findings also demonstrate that working with sex trafficking survivors requires additional competencies such as recognizing the signs of sex trafficking, vulnerable populations, and the processes by which traffickers force people into sex trafficking. We discuss these findings in more detail and identify implications for counselor training and practice.
Keywords: sex trafficking survivors, counseling, phenomenological, trauma, competencies
Sex trafficking of any individual is a significant concern globally. In 2000, the United States government enacted the Victims of Trafficking and Violence Protection Act of 2000, which defined sex trafficking as “the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery” or “when the person induced to perform such act has not attained 18 years of age” (§ 103). Although the United States’s efforts fully meet the minimum standards established by the Victims of Trafficking and Violence Protection Act of 2000 to eliminate severe forms of trafficking, the Department of Justice initiated a total of 210 federal human trafficking prosecutions in 2020, of which 195 involved predominantly sex trafficking (U.S. Department of State, 2021). As stated in the Trafficking in Persons Report (U.S. Department of State, 2021), all 50 states, the District of Columbia, and U.S. territories have reported all forms of human trafficking over the past 5 years. With an estimated 4.8 million people victimized by sex trafficking (International Labour Organization, 2017), it is important to understand how counselors identify, provide services to, and advocate on behalf of sex trafficking survivors within the counseling setting.
Sex Trafficking and Mental Health
As a form of human trafficking, sex trafficking exposes individuals to torture; kidnapping; and severe psychological, physical, and sexual abuse. Physical health consequences of sex trafficking include general health complications (e.g., malnutrition), reproductive health consequences (e.g., sexually transmitted diseases, unwanted pregnancies), substance abuse, and physical injuries (Grosso et al., 2018; Lutnik, 2016; Muftić & Finn, 2013). Psychological abuses are numerous and can include intimidation, threats against loved ones, lies, deception, blackmail, isolation, and forced dependency (Thompson & Haley, 2018).
Constantly experiencing atrocious physical and psychological abuses creates mental health consequences such as depression, post-traumatic stress, dissociation, irritability, suicidal ideation, self-harm, and suicide (Cole et al., 2016; O’Brien et al., 2017). Survivors of sex trafficking may exhibit severe mental illness, including schizophrenia and psychotic disorders, increased risk of compulsory psychiatric admission, and longer duration of psychiatric hospitalizations (Oram et al., 2016). Moreover, social distancing and the global economic downturn due to the COVID-19 pandemic increased online sexual exploitation and the number of individuals vulnerable to sex trafficking (U.S. Department of State, 2021).
Because of the prevalence of sex trafficking, the health consequences that result from it, and the diverse areas in which counselors practice (e.g., community clinics, private practices, behavioral health departments, college/universities, K–12 schools), counselors must be prepared to work with sex trafficking survivors (Interiano-Shiverdecker et al., 2022, 2023; Litam, 2017, 2019; Romero et al., 2021; Thompson & Haley, 2018). Standards required by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) prepare counselors to demonstrate clinical competencies to address a variety of circumstances, including traumatic experiences, across various continuums of care (e.g., inpatient, outpatient). Clinical mental health counselors with specialization in substance abuse and marriage, couple, and family counseling can also address other comorbid issues typically encountered with sex trafficking clients such as substance abuse and relational difficulties (CACREP, 2015; Litam & Lam, 2020). Early incidence of sex trafficking (12–16 years for girls, 11–13 for boys and transgender youth; Franchino-Olsen, 2019) demands the attention of school counselors trained to promote the academic, career, and personal/social development of school-aged children (American School Counselor Association [ASCA], 2022; CACREP, 2015). Therefore, first-hand accounts of counselors providing services to this population can provide an overview of current needs, challenges, and recommendations for clinical practice and research.
Sex Trafficking Research in the Counseling Profession
A recent review of the literature showed increased attention to sex trafficking coverage in top-tier counseling journals. Conceptual pieces reviewed relevant information on sex trafficking, counselor awareness, and counseling implications (Browne-James et al., 2021; Burt, 2019; Litam, 2017; Thompson & Haley, 2018). Empirical studies explored counselors’ attitudes toward sex trafficking (Litam, 2019; Litam & Lam, 2020), assessment for the screening of sex trafficking (Interiano-Shiverdecker et al., 2022, 2023; Romero et al., 2021), mental health treatment programs and modalities for sex trafficking (Johnson, 2020; Kenny et al., 2018; Schmidt et al., 2022; Woehler & Akers, 2022), and survivors’ recovery stories (Bruhns et al., 2018). Thompson and Haley (2018) reported a need for more training and education for counselors on sex trafficking. In a study done by Litam and Lam (2020), results indicated that counselor training in sex trafficking increased awareness. As a response, Interiano-Shiverdecker et al. (2023) developed an initial list of child sex trafficking competencies for counselors.
Although these studies provide relevant information for counselors’ work with sex trafficking, they do not focus on the experience of providing care for sex trafficking victims and survivors. Exploring counselors’ experiences provides a significant breakdown of current mental health care for this population. In other words, what does providing care for this population look and feel like in reality and what competencies work when serving sex trafficking victims and survivors? Only one phenomenological study focused on this inquiry, but this study examined therapists’ experiences working with foreign-national survivors of sex trafficking in the United States (Wang & Park-Taylor, 2021). Although this study presents important findings, it explored counselors’ work with only a certain group of sex trafficking individuals. Despite incomplete records, most data indicate that U.S. citizens are equally vulnerable to sex trafficking. For example, the National Human Trafficking Hotline (n.d.), which maintains one of the most extensive data sets on human trafficking in the United States, indicates that U.S. citizens comprised approximately 40% of their callers. The current study seeks to expand on the work of Wang and Park-Taylor (2021) by obtaining first-hand accounts of counselors providing services to sex trafficking clients in the United States and providing an overview of needs, challenges, and recommendations for clinical practice and research. The guiding research question for this study was: What are the lived experiences of counselors working with sex trafficking survivors in the United States?
Method
Using transcendental phenomenological research, the researchers—Claudia G. Interiano-Shiverdecker, Devon E. Romero, Katherine E. McVay, Emily Satel, and Kendra Smith—sought to understand counselors’ experiences working with sex trafficking survivors. A transcendental phenomenological method was best suited for this study because it allowed us to provide thick descriptions of the phenomena while employing bracketing techniques to explore participants’ experiences outside of our perspectives (Hays & Singh, 2012). Utilizing Moustakas’s (1994) modification of Van Kaam’s method, we sought to explore the occurrences of counselors working with sex trafficking survivors and collectively met to address any biases that came up during data analysis.
Researchers as Instruments
At the time of the study, Interiano-Shiverdecker and Romero were counselor educators at a university in the Southern United States with recent sex trafficking publications and experience working with youth vulnerable to sex trafficking in community and school settings. McVay was a doctoral candidate and a licensed professional counselor who was practicing as a social–emotional wellness counselor at a private school. Satel and Smith were master’s students in a clinical mental health program. Our desire to explore this topic stemmed from a limited discussion of sex trafficking in the literature and sought to include the voices of counselors. As the research team, we are all involved in a research lab dedicated to understanding sex trafficking and how counselors can better serve sex trafficking survivors. As such, we had varying levels of experience with research and engagement with sex trafficking. Satel and Smith were new to research, including topics surrounding sex trafficking. Therefore, Interiano-Shiverdecker and Romero’s broader understanding of the topic could have influenced newer members. For example, Interiano-Shiverdecker assumed that codes would resemble counseling competency categories (e.g., knowledge, skills, awareness). To reduce researcher bias, we engaged in weekly debriefing meetings for approximately 5 months for ongoing discussion of our perspectives and preconceived notions throughout data analysis. We documented our biases in journals, checked in on them during meetings, and referenced participants’ quotes to prevent imposing our assumptions of the data.
Participants and Sampling
After receiving IRB approval from the university, we sought participants through purposeful sampling and snowball sampling. Purposeful sampling strategies included reaching out directly via email to counselors who fit the study criteria and sending two calls for participants on an email mailing list for counselors and counselor educators (i.e., CESNET). For direct emails, McVay created a list of individuals who fit the criteria from Interiano-Shiverdecker and Romero’s professional network and an internet search. We also engaged in snowball sampling methods through recruited participants involved in the study. Inclusion criteria included counselors over the age of 18, who had previously or were currently working with children or adults who had been sex trafficked. Participants confirmed meeting the inclusion criteria by responding to a demographic questionnaire before beginning the interview. Following the qualitative researcher’s recommendation of sample size, we sought a range between five and 25 participants for this study (Creswell, 2013; Moustakas, 1994). Counselors who agreed to participate completed the consent forms, a demographic form, and a one-time Zoom interview. Participants received a $25 gift card for their involvement in the study. We recruited for about 5 weeks after interviewing 10 counselors. After the tenth interview was completed and we concluded the first round of analysis for all interviews, we felt that data saturation was achieved when similar codes showed up throughout the data.
The resulting participant pool consisted of 10 counselors (nine female and one male) ranging in age from 27 to 61 years (M = 40.7, Mdn = 38.5, SD = 11.1). Seven participants identified as White, two participants identified as Hispanic, and one participant identified as Asian. The participants also identified their employment setting: university (n = 1), agency (n = 3), and private practice (n = 6). Participants disclosed providing services in one or several states such as Alabama (n = 1), Florida (n = 1), Missouri (n = 1), Nevada (n = 1), North Carolina (n = 1), and Texas (n = 7). One participant also reported providing services to sex trafficking survivors in the United Kingdom. Years working with survivors of sex trafficking ranged from 1 to 13+ years, with a range of three to 50+ clients who disclosed their sex trafficking experience. One participant (Alejandra) who had worked primarily with survivors of sexual abuse did not indicate their number “since a lot of clients I have worked with do not readily admit to being sex trafficked, I’m not sure.” Table 1 outlines participant demographics in more detail.
Table 1
Participant Demographics
| Pseudonym |
Age |
Gender |
Race/Ethnicity |
Work Setting |
Years of Service |
# ST Clients |
CACREP |
| Kimberly |
48 |
Female |
White |
Private Practice |
11 |
30 |
Yes |
| John |
38 |
Male |
White |
University |
11 |
5 |
Yes |
| Stacy |
33 |
Female |
White |
Private Practice |
8 |
3+ |
Yes |
| Alejandra |
54 |
Female |
Hispanic |
Agency |
Unsure |
Most of career |
No |
| Fen |
39 |
Female |
Asian |
Private Practice |
5 |
4 |
Yes |
| Cassandra |
33 |
Female |
White |
Private Practice |
5 |
50+ |
Yes |
| Tiffany |
27 |
Female |
White |
Private Practice |
1 |
25 |
Yes |
| Amanda |
29 |
Female |
White |
Private Practice |
4 |
5 |
Yes |
| Ana |
61 |
Female |
Hispanic |
Agency |
13+ |
20 |
Yes |
| Cristina |
45 |
Female |
White |
Agency |
3 |
10+ |
No |
Note. Years of Service = Years providing services to ST survivors; ST = Sex trafficking; CACREP = Program accredited by the Council for Accreditation of Counseling and Related Educational Programs.
Data Collection Procedures
To follow phenomenological research methods, Interiano-Shiverdecker trained the doctoral student (McVay) in conducting semi-structured interviews. The researchers developed interview questions based on the purpose of the study and from a review of the literature. Interiano-Shiverdecker and McVay completed the interviews. Following Moustakas’s (1994) recommendations, the interview protocol consisted of 12 semi-structured, open-ended questions that invited an in-depth discussion of their experiences. To create our interview protocol, we reviewed current literature in counseling on sex trafficking, particularly qualitative studies (Browne-James et al., 2021; Bruhns et al., 2018; Johnson, 2020; Wang & Park-Taylor, 2021; Woehler & Akers, 2022). Based on this review and Interiano-Shiverdecker’s experience in qualitative research, we decided to focus not only on counselors’ experiences with working with this population but also on their perspectives on the identification, prevention, and impact of sex trafficking on their clients. The complete interview protocol can be found in the Appendix. Interviews lasted from 26 to 69 minutes in length and occurred via Zoom because data collection occurred in 2021 and it was the most appropriate medium to respect social distancing and obtain a national sample. According to our IRB approval, our data collection presented no more than minimal risks for the participants. All interview questions followed a respectful disposition using open-ended questions to engage participants. However, McVay explained before beginning the interviews that participants could stop, pause, or opt out of the interview if the questions brought too much emotional distress. No participant requested the interview to be stopped or paused. During the interviews, we used counseling skills to facilitate the conversation and to build upon the experiences discussed. We recorded and de-identified all interviews for verbatim transcription.
Participants also completed a demographic questionnaire before the interview to confirm their eligibility for the interview and obtain information on their age, gender, race/ethnicity, work setting, CACREP accreditation and degree, years working with sex trafficking survivors, and the number of clients they worked with who identified as trafficked.
Data Analysis
Utilizing Moustakas’s (1994) modification of Van Kaam’s data analysis, the research team engaged in the seven steps proposed by this approach. Data analysis and management relied on the use of NVivo software (Version 12). Interiano-Shiverdecker provided training in data analysis to McVay, Satel, and Smith. Interiano-Shiverdecker, McVay, Satel, and Smith engaged in the first step by individually analyzing transcripts and engaging in horizontalization of meaning units (Hays & Singh, 2012) to create in vivo codes for all nonrepetitive, nonoverlapping statements (meaning units). Second, we merged all files to determine the invariant constituents through a process of reduction and elimination. This first process of reduction allowed us to determine what was necessary and sufficient data to understand the phenomenon (Moustakas, 1994). The team then assigned themes or clusters of meaning to similar statements (third step). From the clusters of meaning, we created an initial codebook based on the discussions and findings from individual data analysis. We used the initial codebook to examine the themes against the dataset, ensuring that it was representative of participants’ experiences (fourth and fifth steps). As a team, we discussed any disagreements and worked on the data until we achieved a consensus. We worked out disagreements by discussing any opposing views and voting as a group on the best decision. We subsequently created textural descriptions through participants’ verbatim quotes, as well as created structural descriptions by examining the emotional, social, and cultural connections between what participants said (sixth step). Finally, we created composite textural-structural descriptions that outlined the reoccurring and prominent themes across all participants by organizing the themes into subthemes and ensuring that they represented all (if not most) participants’ experiences. After this analysis, we felt we achieved data saturation. After the completion of the initial analysis, Romero reviewed the data as a peer reviewer and offered suggestions. The entire research team reviewed the suggestions and came together to incorporate them until we reached a consensus and developed the final codebook.
Strategies for Trustworthiness
To limit the effects of researcher bias, we employed several strategies for trustworthiness. These included reflexive journals, triangulation of researchers, peer debriefers, an external auditor, member checking, and thick descriptions to ensure ethical validation, credibility, transferability, confirmability, sampling adequacy, and authenticity of our analysis (Hays & Singh, 2012). We engaged in reflexive journaling and weekly bracketing meetings during our individual and group data analysis to discuss codes, potential themes, and our assumptions shadowing the participants’ words. Researchers on the team brought varying levels of experience with research and the topic of sex trafficking, which we believe helped balance our subjective analysis of the data. We engaged in two rounds of member checking with the participants, one occurring after the transcription of the interviews and the second one after we wrote the themes. No participants changed the transcription of their interview or disagreed with the presentation of the themes. After the formulation of the themes from the original coding team, Romero served as a peer debriefer and reviewed the themes, key terms, and raw data, allowing participants to make recommendations on the content presented. This division in the research team allowed for another check outside of the original designated research team. An external auditor, a counselor educator with experience in conducting qualitative research, also reviewed the NVivo file and the write-up of the findings. The external auditor agreed with our data analysis procedures and presentation of the findings. He did provide suggestions to reduce the repetition of our first and second themes, which we implemented. Finally, we provide thick descriptions of our data collection and analysis procedures and present our results with direct quotes to ground our work.
Results
We identified four prevalent themes about mental health counselors’ experiences with sex trafficking survivors: (a) counselor knowledge: “learning curve,” (b) counselor skills: “creating a safe space to dive into work,” (c) counselor attitudes: “being able to listen to the client’s story,” and (d) counselor action: “more than just a counselor.” We use pseudonyms to present our results.
Counselor Knowledge: “Learning Curve”
All participants emphasized the importance not only of understanding trauma but also of gaining sex trafficking–specific knowledge throughout their work with survivors. Tiffany noted a “learning curve” when working with this population, despite working with trauma for most of her career. We categorized this theme into two subthemes: (a) understanding trauma work and (b) understanding sex trafficking and survivors.
Understanding Trauma Work
To work with sex trafficking, all counselors spoke about the importance of having general knowledge of trauma work. The most prominent topics included multicultural, legal, and ethical considerations. Important multicultural considerations for counselors involve understanding group differences between their clients (e.g., gender, race, age) and working from a culturally sensitive framework. Kimberly emphasized that “we really need people to not only have cultural sensitivity but also encourage those who are of other races to counsel these girls,” adding that “they need someone that’s like them from the same culture . . . to relate culturally to somebody.” Legal implications included understanding consent, informing clients of their limits of confidentiality when assessing for risk, and their role as mandated reporters. In reference to ethical practices, consultation and supervision arose as with any other trauma work. Stacy noted that it was “important for us to talk to one another if something’s going awry.”
Many participants conveyed how crucial it was for them to understand healing and its complexities. Cristina shared that clients are “going to have their ups and downs,” with Amanda echoing that there are “so many layers to the healing process.” Kimberly felt it important to remind herself that “you’re probably not going to see the seeds that you plant develop a lot of times.” Another important aspect of healing trauma, mentioned by half of the sample, was understanding clients’ stages of change. Stacy shared that one of her clients “went back to her hometown and relapsed immediately. And that’s also a hard thing to deal with—to know that I felt like we had some good sessions . . . and then it’s, ‘Wait a minute. You went back to the relapse [sex trafficking].’” Cristina noted that “especially [when they’re] first out and they’re not quite sure, that pre-contemplation if they want to leave or stay” was very important.
Another important aspect of their work included boundaries and self-care. All participants acknowledged that at some point in their careers, it was challenging to practice healthy boundaries. Cassandra acknowledged the following when working with individuals forced into sexual acts, “I wish I could take all the ladies I’ve ever worked [with], that have danced on stripper poles for money, unwillingly, and just like put clothes on them and wrap them up and hug them.” She added,
[It] can get really tricky when we start answering our phone because it’s an emergency all the time . . . and it’ll wear you out, your batteries will wear out, and you’ll end up having this dual relationship that will end up hurting her because . . . you’re not her friend.
It was helpful for Cassandra to remind herself that she was not the client’s parent. Rather, she shared, “when I hear things like that, I have to remind them that this is my job, this is what I do for a living.” Implementing healthy professional boundaries reduced burnout and facilitated self-care. Participants highlighted activities such as meditating, doing yoga, or taking the occasional day off. The counselors heeded that self-care also included managing their caseload to limit emotionally heavy clients or seeing a personal counselor themselves, as Cassandra and Amanda respectively noted. Amanda said, “you definitely have to secure your oxygen before you can secure other people’s.”
Understanding Sex Trafficking and Survivors
All participants explained that working with this population required them “to understand what sex trafficking is and . . . the many different ways that it looks,” as stated by John. He elaborated that “it takes many different forms and shapes,” some of which may not be immediately recognized as trafficking. Participants agreed that sex trafficking can often be much more discreet than one might anticipate. Tiffany commented on media portrayals like the film Taken, stating that the real experience is often much less dramatic: “Listening to their stories, it’s very, very subtle . . . like, if you do this then I’ll pay for your college tuition . . . and then from there it gets bigger.” Similarly, Cassandra noted that sex trafficking “can be, like, a bunch of underaged females, thrown in the back of a truck and trafficked across the United States” or people that “have their own residences, that don’t actually live with the trafficker, or they live with a family member that’s trafficking them.”
Counselors learned that although anyone can be trafficked, some populations are more vulnerable. According to Fen, these populations include clients with cognitive disabilities, immigrants, emotional abuse survivors, clients with PTSD, and clients with addictions. Other populations mentioned included the LGBTQ+ population, people recently released from jail/juvenile detention centers, college students with debt, and people in financial need.
The participants’ work also required them to learn how clients were recruited and what kept them from leaving sex trafficking. John and Amanda noted that many survivors knew their traffickers or were introduced to them by family, friends, or a romantic partner. Ana explained that traffickers may kidnap people from big sporting events or from opposing gang(s) or may train survivors to recruit and groom for them. She also worked with women recruited online from abroad and trafficked once they arrived in the United States. Counselors also learned about the numerous tactics used by traffickers, including the trauma bond, coercion, and control. John noted that traffickers often use manipulation: “The common theme was ‘If you do this, you’d really be helping me out. You wanna see me be okay?’ or ‘You don’t want me to go to jail, do you?’” Cassandra reported working with a client whose parents used “an odd twist on Christianity” and the principle of “respect your elders” to traffic her. Other tactics mentioned were threats of violence against survivors and their families, branding or tattooing survivors, stalking, taking survivors’ IDs, gaslighting, and fear. Cassandra also observed that trafficking was “so alluring . . . there’s a lot of money in that . . . so much about leaving sex trafficking is starting from zero and creating something new.” Amanda recalled a client who “was very upscale and so they lived kind of a lavish lifestyle, and I could see and understand, really emphasize the struggle to like give that up,” particularly when they were worried about providing for their families. Factors that forced individuals into sex trafficking were multilayered. Amanda continued, “so many other facets and like layers to this. It’s like an onion.”
As a result, counselors learned about the overall impact of sex trafficking on survivors’ mindsets, behaviors, and presenting symptomology. As noted by Kimberly, sex trafficking impacted every aspect of survivors’ lives. Tiffany noticed that many of her clients were initially very fragile and mistrusting of everyone, while Cristina and Stacy shared that it was common for their clients to display guarded and closed-off body language. John’s work taught him that sex trafficking “affects [clients] in terms of intimacy and trust, and that trickles into their relationships, whether it’s with family, roommates, or romantic partners.” The counselors’ work with sex trafficking survivors included clients with an array of presenting concerns. Cassandra observed clients with complex PTSD, substance use issues, self-harm behaviors, suicidal ideation, self-hatred, self-blame, feelings of insecurity, an inability to trust, and eating disorders. Ana also noted that clients presented with anxiety, depression, paranoia, and physical concerns such as sexually transmitted diseases (STDs) and sleep problems.
Counselor Skills: “Creating a Safe Space to Dive Into Work”
All participants recognized that because of the nature of their work and their clients, they needed to “create a safe space to dive into work,” as stated by Tiffany. To do so, they needed to build skills in two main categories: (a) assessment and ensuring safety and (b) processing trauma. Amanda explained, “I think all of that stuff [assessment and ensuring safety] really has to come first before we can do any really heavy work and therapy. . . They have to be stable before they can really dig into whatever they want to dig into.” Although this separation provides clarity, counselors’ experiences were also more fluid, at times requiring them to use skills particular to ensuring safety while processing trauma and vice versa.
Assessment and Ensuring Safety
All counselors’ experiences of assessment and ensuring safety consisted of effectively engaging with their clients during the intake interview, assessing risk, applying crisis skills, and formulating personalized treatment plans. Based on her experiences, Cristina spoke about the importance of building rapport during that initial interview: “When I do our initial assessment with them . . . I have the assessment, but I’m having a conversation with them.” She also learned to discuss confidentiality and mandated reporting with her clients to explain her role as the counselor while also giving them a choice: “I tell them straight out, like, ‘Hey, you tell me this, I have to report it, I have to call law enforcement . . . so how do you want to do it?’” Cassandra found that obtaining a thorough history of the client was a critical part of the process:
When addressing trauma, I don’t just go back to when the trafficking started. I go all the way back, make sure that I have that thorough history, because 99 times out of a 100, from my experience, that was not the first trauma that person experienced.
Seven participants spoke about learning the signs of sex trafficking and knowing what questions to ask to obtain more information and determine a person’s exposure to sex trafficking. Amanda explained, “I don’t think I’ve ever had somebody start off within an intake session be, like, ‘Hiya, so I was trafficked.’” Participants learned to ask about phone use and the number of phones owned, the extent of drug use, sexually transmitted diseases, wanted and unwanted pregnancies, boyfriends and their ages, and sexual behaviors such as the use of a condom. When assessing, Alejandra learned to “ask questions that minimize you coming across as being shaming or judging.” At the same time, some counselors spoke about the lack of sex trafficking assessments that could facilitate this part of their work. Alejandra explained that she “did an assessment at work yesterday, and there, there are no questions about sex trafficking. . . . There are questions about abuse, but it is inferring more [about] sexual abuse, physical abuse, emotional abuse versus sex trafficking.” Fen echoed this sentiment by wishing there was a more rigorous psychosocial interview that assessed risks associated with sex trafficking because “at times people do hide and at times people don’t disclose.”
All counselors agreed that a significant aspect of ensuring safety for their clients was collaborating with clients on safety plans. Counselors took the time to develop a “well thought out” safety plan with their clients, as stated by Alejandra. Stacy explained how she helped the client brainstorm ways to feel safer, including leaving town for a while or taking steps to “create a new account, changing her look a little bit . . . getting [a] new phone number.” Collaboration was not only utilized to respect clients’ autonomy but also to instill hope—“Hope that you know that you have a future,” stated Cristina. Ana elaborated, “seeing what they want for themselves and their lives, like, where do you want to go with your life . . . if you didn’t have this going on, you know, what is it you would like to do for yourself?”
Processing Trauma
To process trauma, all counselors listed skills, interventions, and therapies they found helpful with this population. Utilizing foundational skills (e.g., reflection, open-ended questions, appropriate self-disclosure) to build rapport was the most referenced code in this section, addressed by all participants. Cristina saw the benefit of learning how “to connect very quickly.” Stacy added, “I would definitely start relying a lot more on the rapport when I work with trauma.” Counselors also found it helpful to have a toolbox that included creative approaches and interventions that helped clients reclaim power, develop a support system, improve self-esteem, build and discover resiliency, and utilize the client’s strengths. Psychoeducation, mentioned by nine participants, included teaching their clients about sex trafficking because as John explained, “clients don’t always know that they are being trafficked.” Psychoeducation of sex trafficking requires explaining fraud, force, and manipulation. Kimberly explained how a client did not think she was trafficked because her partner did not have her “locked in a closet. I don’t got chains around me. I’m not his slave . . . I get up and get myself dressed. I go out there and meet these guys . . . I cooperate when he’s taking pictures of me.” To help her client reevaluate her situation, Kimberly utilized motivational interviewing–based questions such as “Would you let your sister do this?” or “What would be the benefits of leaving your situation?”
Although most counselors felt that an integrative approach to counseling worked best with sex trafficking clients, the therapies most mentioned included dialectical behavioral therapy, narrative therapy, and eye movement desensitization and reprocessing therapy. Counselors recommended individual treatment to process trauma, although four participants also mentioned family and group counseling. Fen found family therapy helpful “if the family wants to get involved in the practice” and “if there are family members who are ready to support them and come with them and who are aware of this.” Other participants mentioned the benefits of providing group counseling for sex trafficking survivors. Cassandra recalled how members of a support group she facilitated “connect with each other, they know that they’re not alone, they give each other honest feedback. . . . It has been super empowering.” Yet Alejandra, Fen, and Tiffany found that group counseling may not be well suited for all clients. “Group therapy doesn’t work really well because you know every survivor is different, and they don’t want to open up in front of others until they have worked through the process for a long time,” explained Fen.
Because of the nature of their work, counselors recognized that an essential skill to processing trauma was learning how to manage countertransference. Cristina spoke about how as “clinicians, we want to save all of them.” For this reason, Kimberly recognized that it was important for her to understand her attachment style. Cassandra recalled nights when she would go home and “worry about [if] I am going to see this client again.” Ana left sessions “shaking sometimes from those places . . . ’cause the stories I would hear.” Stacy highlighted that it was also difficult at times to manage the lies. She explained, “I was a little frustrated because I knew that she was hiding things . . . obviously it just wasn’t that time and that’s okay.” As a result, counselors found it essential to process their emotions. Kimberly explained that “if you haven’t emptied your cup of all the sad, mad, bad before you come into that office with them . . . you’re going to flip your lid whether it’s in front of them or behind closed doors.”
Counselor Attitudes: “Being Able to Listen to the Client’s Story”
All participant interviews illuminated thought patterns and beliefs they needed “to listen to the client’s story,” as stated by John. Counselors learned to personify certain attitudes by (a) valuing empathy and validation and (b) embodying a sense of safety.
Valuing Empathy and Validation
All participants highlighted the importance of embracing a philosophy of empathy and validation in their work with clients by being warm, genuine, open-minded, patient, and nonjudgmental. Participant interviews described various mechanisms to embody these attitudes. For instance, a consistent approach they took was to respect and empower the clients’ choices and, ultimately, believe in and provide client autonomy through supportive and nonjudgmental means. Ana emphasized, “I think that’s huge for those whose choices were taken away. . . . It’s offering them a choice, and I think that’s very empowering for them.” Fen echoed this message stating, “You can’t push—you can definitely motivate—but you cannot just push.” Kimberly learned to be patient: “You’ll end up getting there eventually, just take your time. . . . You have to build that rapport and trust.” Cassandra stated, “Another thing I would say is don’t make any assumptions. . . . Everybody’s experiences, although there are similarities, every experience is so different.” Cristina described the shock value of hearing survivors’ stories and how essential it was for her to remain nonjudgmental and aware of her biases. Amanda embodied “those Rogerian qualities, like that open-mindedness, empathy, warmth, genuineness, authenticity—those things are all really important to utilize when meeting with that population, or any population.” Cristina provided an example of how she conveyed this to a client by saying, “I’m here if you need me. . . . There’s no judgment happening, I’m just glad you’re here.”
Counselors also shared a philosophy that validated clients’ experiences. Fen believed in “just making clients feel normal,” while Cassandra noted how helpful it was for her to approach clients’ behaviors as “normal reactions to abnormal situations.” An important attitude communicated by John was that “they are survivors.” Even though others and possibly even the client themselves might use the word victim, he found it helpful to have “the conversation about being a survivor versus a victim.” Tiffany further explained, “I’ve noticed just in working with sex trafficking survivors . . . it seems very hard for them to say the word ‘abuse’ or view themselves as anything other than a victim.” She found value in seeing the client as “a survivor” and teaching this perspective to the client.
Embodying a Sense of Safety
All participants embraced attitudes that created and maintained a safe environment for their clients. Fen explained that as the counselor, “you’re the only safety net for that person” who provides safety and trust. Cristina reflected on a client who was still in “the life” and returned for help and services when needed. She stated, “she knows that I’m a safe person” and “this [shelter name] is her home, this is where she felt safe. But [she] knew she couldn’t get out of this life yet because she wasn’t ready to.” Fen explained that “there is shame, there is guilt, there is fear, and apprehension of being caught . . . so, one has to make them feel safe.” Some participants communicated and provided safety by creating a “homier and safer” office space or by buying a client’s favorite snacks and beverages, as described by Cassandra. Alejandra spoke of establishing “an environment where it’s safe to talk about taboo subjects” such as “having been a mule or whatever they did, you know, whatever sexual acts.”
Six of the participants also spoke of attitudes that promoted consistency and predictability. Kimberly stated, “That’s something they’ve never had in their life; you know, so while you’re doing all this other stuff, be consistent.” Several participants noted how difficult it was for their clients to have continuity with counselors. Kimberly shared:
Counseling someone who’s had this kind of trauma takes a long time . . . once you leave and can’t continue that counseling process, the likelihood of them going back to the counseling is very slim to none. . . . Even though they were resistant to building that rapport with you at the same time, deep down inside they’re connecting with you.
Similarly, a few participants learned to be consistent in their messages shared with clients and accessibility to clients. For instance, Stacy spoke of the need for congruency between actions and words when working with these individuals: “Trust is such a fleeting word . . . it has to be action, sometimes, speaks louder than the words.”
Counselor Action: “More Than Just a Counselor”
All participants realized that working with this population required them to reevaluate their role as the counselor. They learned that clients required “more than just a counselor,” as stated by Kimberly. Therefore, the fourth theme elucidated actions that counselors found necessary to help clients recover from their experiences. We categorized counselor action into two subthemes: (a) client advocacy and (b) engaging with social work/workers.
Client Advocacy
Over half of our participants spoke about the importance of advocating for clients. Cristina talked about how some clients did not have a caseworker and needed someone “that’s in their corner.” Counselors spoke about specific needs they advocated on behalf of clients in the life or in recovery. Kimberly spoke about advocating for prison reform, particularly for minority women who went to prison for some of the things they got involved in while being trafficked. Cristina advocated for “easier access to get into drug treatment.” She explained that this was necessary because certain insurances did not pay for certain drug treatments, or it would take too long to get clients into treatment. Although clients would sometimes agree to treatment, it would take several days “to get everything going. . . . by then the kids change their minds, or they run. . . .The obstacles shouldn’t be that hard.” Other forms of advocacy focused on working with and educating police officers to best work with this population. Tiffany explained how many women didn’t trust law enforcement. She believed it was crucial to bridge these services because law enforcement could “get them out of that lifestyle, but then on the other hand, they’re very much like, ‘Don’t trust them.’” Stacy also spoke about advocating for shelters specific to sex trafficking. She remembered a client who visited a shelter once a month and loved it because “she felt safe there versus just, like, a domestic violence clinic . . . they had the awareness of sex trafficking versus just, like, you know, an overnight shelter type of place.”
Participants also taught clients how to advocate for themselves while also respecting their choices. Stacy explained, “It’s not my job to fix what they’re going through, but it is my job to be as supportive as I can.” She understood that she needed to “advocate for them but also having the respect that if they don’t want me to advocate for them, then that’s the place that they’re at too.” Stacy also clarified that at times she does not “really know exactly 100% how I would want to advocate” for clients who had been trafficked. Yet as she continued to reflect, she realized her desire to “seek out more education about it because I do think that it needs to be navigated in a specific way.”
Engaging With Social Work/Workers
The call for advocacy led all counselors to speak about how their work required them to expand their roles to connect clients to resources and collaborate with social workers. Kimberly explained that this population requires “more than just a counselor while they’re in session . . . you’ve really got to start with building a community around them before you get into the deep trauma work.” Counselors provided resources to obtain transportation, financial assistance, government assistance, their GED or college degree, food, employment, stable housing, legal support, childcare, hygiene products, substance treatment, and medical care. Amanda explained that this population requires that their basic-level needs be met to help them feel like they “can function in society and be comfortable,” and Kimberly elaborated:
As a counselor, I used to have a huge list of resources that I could give them, but they also needed guidance from outside of the counseling office. . . . I have, like, eight people with one survivor, that’s how much it took us ’cause it’s so much work for one person. You’re talking about every aspect, everything that you learned as a child growing up. . . . If you want counseling to be successful, they have to have that outside component to help them . . . a counselor can’t do all of that.
Ana partnered up with organizations already doing this work. She particularly spoke about an organization that not only focused on “educating people but also helping these women with resources.” She added that “the residential places they were able to stay in, they were able to finish their education and get an education there, and they also helped them with finding jobs, which was really important for them, too.” She explained that this was particularly important because many of the women she worked with had a violent criminal history. Many company insurances refused to hire women with criminal records, preventing their clients from a second chance at improving their lives. However, John learned to support clients with resources. “I don’t think it’s sufficient to just say ‘Here you go, here’s the resource guide. They have lots of options in there. Good luck.’ . . . Our job doesn’t end with giving the resources,” he explained.
An important point to make is that although some counselors spoke about collaborating with social workers, it seemed that most believe their work resembled “a little more of that, like, case management–type stuff to make sure that they have the resources if and when they want out,” added Cassandra. Kimberly elaborated, “You’re the one that’s helping to get them to [a] place where they can have a relatively stable life . . . but without the resources that come alongside that, they’re gonna go nowhere, [they’re] going to hit a wall every time.”
Discussion
We sought to understand counselors’ experiences working with sex trafficking survivors through a phenomenological analysis. The participants in our study needed to understand and address the different aspects of trauma. Because of clients’ traumatic experiences that resulted in psychological injuries (Cole et al., 2016; Grosso et al., 2018; Lutnik, 2016; Muftić & Finn, 2013; O’Brien et al., 2017), counselors benefited from respecting the process of healing, addressing stages of change, and building a safe and trusting relationship. Counselors overall possessed knowledge of the development of post-trauma responses over time. They knew what to look for and how to best treat traumatic symptoms that permeated all aspects of their client’s lives, particularly sex trafficking survivors’ ability to trust others. Counselors believed that having a trauma-informed approach could reduce instances of re-victimization. Counselors also recognized the importance of self-awareness such as assessment of personal trauma, self-care, restorative practice, and biases regarding how youth are trafficked and by whom.
Yet, our findings demonstrate that working with sex trafficking survivors requires additional competencies as illustrated in previous research (Interiano-Shiverdecker et al., 2023). The participants discussed the need to become educated in recognizing the signs of sex trafficking, vulnerable populations, and the processes by which traffickers force people into sex trafficking to obtain a deeper understanding of the client’s worldview and provide appropriate support (Interiano-Shiverdecker et al., 2023). Participants addressed components—namely force, fraud, coercion, exploitation, power, grooming, and solicitation—commonly used in sex trafficking literature (Bruhns et al., 2018). When asked about the nature of their work, their focus naturally divided into sections that focused on assessing risk and safety planning, processing trauma, and helping the client re-establish their life and their identity. Our findings align with CACREP (2015) recommendations for clinical crisis skills and knowledge while also elucidating their application to sex trafficking survivors. Participants learned to assess for specific sex trafficking signs (e.g., phone usage, boyfriends and their ages, sexual behaviors) and to ask questions that differentiated sex trafficking from other forms of abuse.
Counselors must also understand the differences between sex work (i.e., the voluntary exchange of sexual services for compensation) and sex trafficking (i.e., subjection to the exchange of sexual services due to force, fraud, or coercion or from any person under the age of 18). As Ana shared, most counselors felt that the notion to detect was on their end “because I don’t always think it’s the responsibility of the client to be able to say ‘Hey, I’ve been trafficked.’” Thus, participants indicated that possessing these competencies could help increase the identification of sex trafficking. As such, some counselors may desire more guidance on specific sex trafficking assessments, which scholars have previously noted (Interiano-Shiverdecker et al., 2022; Romero et al., 2021). A content analysis on sex trafficking instruments (Interiano-Shiverdecker et al., 2022) illustrated the importance of asking specific questions to assess for control, confinement, threat, and isolation, as these are the main indicators of sex trafficking. Example items included: “Have you ever felt you could not leave the place where you worked [or did other activities]?” (confinement; Simich et al., 2014, p. 20); “Are you kept from contacting your friends and/or family whenever you would like?” (isolation; Mumma et al., 2017, p. 619); “Do you have to ask permission to eat, sleep, use the bathroom, or go to the doctor?” (control; Mumma et al., 2017, p. 619); and “Has anyone threatened your family?” (threat; Mumma et al., 2017, p. 619).
Moreover, for some sex trafficking victims, the relationship with their traffickers represented an affirming, reliable, and secure relationship in their lives, later used to coerce or force them into sexual, violent, or illegal behavior. Therefore, participants realized that processing trauma would require attitudes and skills that provided emotional safety, patience, and a nonjudgmental process. Survivors’ lack of choice throughout their sex trafficking experience fomented counselors’ abilities to empower clients over their bodies, boundaries, and choices, and help clients reintegrate into society (Interiano-Shiverdecker et al., 2023; Thompson & Haley, 2018). Participants seemed to emphasize that without all the elements mentioned, clients might not disclose their situation or trust the counselor enough to open up, and they might even terminate counseling abruptly.
This last point is connected to our fourth finding, counselor action. Aligned with the Multicultural and Social Justice Counseling Competencies (Ratts et al., 2016), the participants in our study recognized the need to engage in work that advocated for clients within and outside of the session. Despite their dedicated work with clients to process the emotional repercussions of sex trafficking and rebuild their lives, their efforts did not seem enough to support clients in their recovery. So much of what ailed their clients fell on systemic or external forces (e.g., poverty, employment, lack of resources). Although that existed outside of the counselor’s role and verged into another profession, our participants embraced these responsibilities or connected with other professionals. They believed that otherwise, clients would not succeed in their recovery. Our findings present an important reminder that sex trafficking, a modern form of human slavery, is an act of social injustice affecting individuals vulnerable to historical and systemic oppression.
Implications
Our themes add to the existing research with implications for counseling practice, supervision, and education. Scholars (Romero et al., 2021; Thompson & Haley, 2018) have identified counselors as first-hand responders to the early detection and prevention of sex trafficking. Although each trafficking scenario is unique, counselors need to refer to sex trafficking indicators, recruitment and grooming tactics, and manipulative dynamics that prevent individuals from disclosing or leaving sex trafficking. It is important for counselors to dispel common myths of sex trafficking and understand that sex trafficking may appear differently than one may expect. Amanda alluded to clients who defined their experience as a “lavish lifestyle” and were lured by the financial benefits of sex trafficking. We caution counselors not to misinterpret sex trafficking as a “lifestyle,” as this implies choice. There may be a myriad of invisible factors contributing to their circumstances such as trauma bonding and financial instability.
Participants agreed that an integrative approach with interventions that addressed complex trauma (e.g., dialectical behavior therapy, eye movement desensitization and reprocessing therapy) worked best when working with sex trafficking. We encourage counselors to not only become familiar with such modalities but also to conceptualize any treatment modality through a trauma-focused lens that considers how sex trafficking impacts all aspects of a client’s life and how they will interact in session. Participant narratives indicated that clients could present with defiant behaviors, distrust, angry or irritable mood, and refusal to comply with treatment. These themes underscore the importance of a counselor’s ability to create safe, trusting, and empathic relationships that allow the client to disclose risk and eventually process trauma. Counselors should also integrate a strong rapport with sex trafficking clients by demonstrating unconditional positive regard, authenticity, and empathy with any treatment modality chosen. Although counselors establish a strong therapeutic relationship, they can integrate other counseling goals, including psychoeducation, assessing for risk, supporting clients through the stages of personal change, and helping the client rebuild and reintegrate into society. Based on the nature of their work, managing countertransference and self-care represents an essential instrument to maintain balance while engaging in emotionally draining clinical work. We encourage counselors to seek supervision, connect with colleagues, and practice regular self-care routines to avoid experiencing burnout, secondary trauma, and countertransference. Additionally, counselors should connect clients to services that provide basic needs (e.g., safe and stable housing, food). When clients lack basic physiological needs, they may struggle to focus on higher-order needs such as developing a safety plan or emotion regulation. Counselors can engage in legislative advocacy by writing letters to judges, sharing clinical experiences with senators, and providing training on sex trafficking victim identification and treatment. It is important for counselors to build constituency groups with education, governmental task forces, and legislators to lobby for bills that benefit clients, as sex trafficking exists in an ecosystem of community and social contexts (Farrell & Barrio Minton, 2019). Our findings also underscore the limitations of intake interviews when assessing for sex trafficking risk. Although identification and screening tools exist (Interiano-Shiverdecker et al., 2022; Romero et al., 2021), counselors are not always in a setting where a formal assessment is appropriate or accessible.
We encourage educators and supervisors to emphasize the value of informal assessment methods with counselors-in-training. Counselor knowledge of signs, symptoms, and questions to ask during an intake can improve identification efforts. Our findings also hold some implications for training beyond counselor education. Because of the complexities of working with trauma and sex trafficking, counselors intending to work with this population should seek out specialized training. For instance, they may review conference programs for trauma or sex trafficking–specific education sessions. At the same time, counseling programs should evaluate their preparation for counselors to work with sex trafficking. Requiring a trauma course, including content on sex trafficking and complex trauma throughout the curriculum (e.g., trauma, grief, addiction counseling courses), inviting guest speakers, and providing training opportunities and workshops for students and community counselors are all suggestions to ensure that counselors obtain the necessary knowledge and skills to work with this population. We believe that more training opportunities can minimize any possible misunderstanding of sex trafficking, expectations on clients to disclose, and re-victimization of clients that leads to early termination of counseling.
Limitations and Future Directions
The nature of our sample holds some limitations for the interpretation and application of the themes from this study. We collected data from single data sources (i.e., individual interviews); additional interview sources (e.g., focus groups) may have contributed more information. Moreover, lack of racial and gender diversity was a limitation in this study because most participants identified as White and female. We noticed that participants did not discuss racial and gender differences in clients’ experiences of sex trafficking. This result could have originated from our interview protocol that sought to gain an overall understanding of sex trafficking experiences and therefore did not request this information. Participants’ demographic profiles may have also provided a limited perspective of the experiences of Black, Indigenous, and/or people of color. We also did not require CACREP accreditation or specific years of practice as part of our inclusion criteria. Although all our participants were licensed professional counselors, they had different degrees in mental health, a variety of clinical practice, and did not all graduate from CACREP-accredited programs. During our interviews, we did not define sex trafficking to the participants and engaged in open-ended questions that inquired about their experiences. Participants’ responses are based on their definition of sex trafficking, which can vary and might not be accurately distinguishable from sex work. As is the case with all qualitative research, counselors and scholars should consider the transferability of these findings to other client populations and with counselors. For example, the findings of this study can be applicable to professional school counselors, but the recruitment of school counselors as participants would have provided greater insight into the roles and responsibilities of counselors in schools. Furthermore, we did not include client perspectives in this study; therefore, even though our participants’ perspectives when working with sex trafficking survivors is very insightful, they may not have an accurate representation of clients’ experiences in session.
Based on these limitations, we recommend scholars explore individual and external factors that can impact counselors’ work with sex trafficking survivors. For example, we did not explore within-group differences (e.g., race, gender, sexual orientation, religion) between counselors and cross-cultural interactions between clients and counselors. These factors are important to consider and reflect on when building trust and a sense of safety for the client, particularly when considering current conversations around racial tension in the United States. A more in-depth analysis of these considerations could facilitate a better understanding of how multicultural traits play a role in counselors’ experiences when working with sex trafficking survivors. Participants’ emphasis on the need for specialized knowledge and skills to work with sex trafficking also warrants research on evidence-based interventions for sex trafficking survivors. Moreover, an examination of the client’s experiences is necessary to garner a holistic picture of the impact of sex trafficking on the client’s healing and counseling process. We also believe that researchers should consider external factors that might impact counselors’ experiences when working with sex trafficking. Considering participants’ discussion of advocacy and engaging with social work/workers, it seems necessary to consider sociopolitical and institutional elements that either hinder or support clients’ ability to leave sex trafficking and obtain access to services that allow them to heal and flourish. As such, counselors working with sex trafficking survivors must consider specific training that allows them to assess for risk, process the emotional ramifications of sex trafficking, and rebuild their lives.
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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Interiano-Shiverdecker, C. G., Romero, D. E., & Elliot, J. (2023). Development of child sex trafficking counseling competencies in the United States: A Delphi study. Journal of Interpersonal Violence, 38(1–2), 1397–1423. https://doi.org/10.1177/08862605221090569
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Woehler, E., & Akers, L. (2022). Repairing the trauma bonds of sex trafficking victim-survivors with animal-assisted therapy. Journal of Creativity in Mental Health, 17(4), 456–458. https://doi.org/10.1080/15401383.2021.1921646
Claudia G. Interiano-Shiverdecker, PhD, LPC-A, is an assistant professor at the University of Texas at San Antonio. Devon E. Romero, PhD, NCC, LPC, is an assistant professor at the University of Texas at San Antonio. Katherine E. McVay, PhD, LPC, is an assistant professor at Texas A&M University–Corpus Christi. Emily Satel is a graduate of the master’s program in clinical mental health counseling at the University of Texas at San Antonio. Kendra Smith is a graduate of the master’s program in clinical mental health counseling at the University of Texas at San Antonio. Correspondence may be addressed to Claudia G. Interiano-Shiverdecker, College of Education and Human Development, One UTSA Circle, San Antonio, TX 78249, claudia.interiano-shiverdecker@utsa.edu.
Appendix
Icebreaker
- Please tell me a little about yourself, your professional background, and clinical experience.
Counseling
- What is important for counselors to know when working with sex trafficking survivors?
- How can counselors best detect when individuals are being sex trafficked or are vulnerable to sex trafficking?
- How can counselors support individuals while they are being trafficked?
- How can counselors help individuals leave their traffickers?
- How can counselors support individuals from returning to their traffickers?
- What do counselors have to know about supporting sex trafficking survivors after sex trafficking?
Personal Experiences and Mental Health
- Please share, to the extent that you are comfortable, your experiences with working with sex trafficking survivors.
- What is the age range in which most of your clients experienced sex trafficking?
- How have these experiences impacted your clients?
- Emotionally and mentally?
- Physically?
- Relationships with others?
- Spiritual/religious beliefs?
- What do you believe has helped them overcome the impact of sex trafficking?
- What services or resources do you believe were most helpful to them?
- What is important about your experience that I haven’t asked you and you haven’t had the chance to tell me?
Jan 17, 2024 | Volume 13 - Issue 4
K. Lynn Pierce
Persistent ableism in higher education, counseling practice, and society necessitates disability justice advocacy. In this article, the author explores the historical context of disability and the importance of disability knowledge for counselors and counselor educators. In addition to discrimination and inaccessibility, able privilege and lack of representation present significant barriers to equity and empowerment of disabled people. Better awareness of disability culture and community-oriented frameworks for the collective liberation of disabled people, such as disability justice, can improve disability equity and allyship within counseling and counselor education.
Keywords: ableism, disability justice, advocacy, allyship, counseling
The disability rights motto, “Nothing about us without us,” highlights the importance of including disabled people in decisions that affect them. However, in a society dominated by able privilege, this motto has at times translated into “Nothing at all.” The absence of disabled representation and empowerment leads to a lack of understanding, empathy, and action toward improving the lived experiences of the disability community.
Over 60 million Americans live with a disability, making them the largest minority group in the United States (Centers for Disease Control and Prevention, 2023). The Americans with Disabilities Act (ADA) defines a person with a disability as “a person who has a physical or mental impairment that substantially limits one or more major life activity” (ADA National Network, 2024, para. 1). These activities include daily tasks like breathing, walking, talking, hearing, seeing, sleeping, taking care of oneself, doing manual tasks, and working. The year 2020 marked the 30th anniversary of the ADA, the major law granting protections to disabled individuals. Yet institutional ableism continues to persist in higher education, counseling practice, and public life. Disabled people face various obstacles, including unresolved barriers to physical access (including of health care and mental health services), social stigma, and insufficient funding for rehabilitation programs. Able privilege (also referred to as ability privilege or able-bodied privilege) is a viewpoint in which non-disabled bodies are considered normative (Lewis, 2022). Able privilege is pervasive in society and continues to contribute to societal stigmatization of and discrimination against disabled bodies, minds, and lives.
Positionality
The positionality of authors engaged in disability justice work is crucial for acknowledging biases and perspectives that influence the writing process. This practice also allows for transparency for readers to better understand the context this article is situated in. This is particularly important given the diversity of cultural norms within and between disability subcommunities and the differences of perception of ableism, access, and disability equity shaped by individuals’ unique experiences of disability.
I identify as a White, queer, disabled academic who aligns with crip culture. The term “crip” is a reclamation of the derogatory slang “cripple,” much as “queer” has been reclaimed by the LGBTQ+ community. I integrate the principles of disability justice and bring lived experience into advocacy, clinical, and research work pertaining to the disability community. I have navigated ableism personally and professionally and am invested in critical examination of ableist systems and advancement of cross-disability liberation. I use an anti-ableist and identity-affirming ideological lens to approach disability advocacy. The use of identity-first language throughout this paper reflects this positionality and is an acknowledgement of many disability subcommunities’ preference for this language.
A Brief History of Disability in the United States
Attitudes and policies surrounding the disability experience in the United States have historically imposed harsh restrictions and exclusions grounded in ableism. In the late 19th and early 20th centuries, the eugenics movement promoted the view that disability was undesirable and needed to be purged from society (Rutherford, 2022). Many proponents of eugenics were scientists, doctors, and policymakers. This contributed to forced sterilization and institutionalization of disabled people, restrictive immigration policies, and segregation in education. These policies, along with social stigma, led to disabled people being socially and economically disadvantaged and pushed to the fringes of society (RespectAbility, 2021).
In the 1970s, The Independent Living Movement and Centers for Independent Living (CILs) emerged as a civil rights campaign spearheaded by and for the disability community (Hayman, 2019). This movement pushed back against the discriminatory environments and paternalistic professionals of the time and focused on providing peer support, dignity, civil rights, and autonomy through direct service and advocacy. At this same time, the 504 protests (referring to section 504 of the Rehabilitation Act) paved the way for the civil rights work that eventually culminated in the passage of the ADA in 1990, which finally extended similar federally protected rights to disability as those that cover race and gender (Cone, n.d.).
Since 2000, disability-related activism has been most prominent online. Within this environment, community-based efforts such as the #SayTheWord movement and disability-related hashtags began to trend on social media. Many within the disability community have embraced X, formerly known as Twitter, specifically because it is free, has accessibility features, and allows for global connection and unprecedented reach to businesses and public figures, as well as other individuals and organizations within the disability community (Wilson-Beattie, 2018). Facebook and other social media groups have been important gathering places for disabled individuals to connect, obtain information about their conditions and available treatments, and find others who can relate to their experiences.
Exclusion of Disability in Education and Practice
The Rehabilitation Act of 1973 and the ADA both extended disability protections into higher education settings. However, because of the lack of protections in these settings prior to these laws, colleges and universities were already built on inaccessible foundations both physically and socially (Dolmage, 2017). This has led to a continued lack of equity for disabled people within higher education.
The National Center for Education Statistics (2018) reported that 19.4% of the undergraduate student body report having a disability, but only 11.9% at the graduate level. The Center for College Students with Disabilities reported that less than 4% of faculty members have disabilities (Grigely, 2017).
This suggests barriers to recruitment and retention and/or biases that prevent disclosure of disability identity. Despite the requirements under the Rehabilitation Act and ADA to provide equitable access, providing disability-related supports is often in conflict with ableist systems within higher education. For example, very few universities and colleges embrace a holistic and affirming model to support disability inclusion on their campuses and instead use an accommodation-only–focused approach. Most colleges and universities do not have a disability cultural center or student organizations focused on disability, despite the benefits for students and the community that such a center can provide (Elmore et al., 2018).
Disability and Counselor Education
Unfortunately, there is very little research available on disability within counseling and counselor education. Disability is often absent from captured demographics in our research, including when studies focus on the experiences of diverse counselors, counselor educators, and students. There is no information currently available regarding disability representation among counselor educators or counseling leadership, and very little about the experiences of disabled individuals within the profession or even the experiences of disabled clients with professional counselors.
Counselor education programs, apart from rehabilitation-specific classes, seldom focus on disability topics. According to Feather and Carlson (2019), 36% of faculty surveyed believed their program was ineffective at addressing disability topics, while only 10.6% believed their program to be “very effective” in this content area. Faculty self-assessment of competence to teach disability-related content correlated significantly with previous work or personal experience with disability, underscoring the importance of exposure to and training about disability-related concepts being infused across core areas. Key elements related to disability competence such as accessibility, able privilege, disability culture, and disability justice are explored in the following sections.
Considering Accessibility
Accessibility is a word that is often co-opted in diversity, equity, and inclusion (DEI) spaces to mean attainability, affordability, inclusion, etc. However, accessibility is a concept that is legally related to the ability of disabled people to equitably interact with built environments and services. The Office for Civil Rights (OCR) defines accessibility as:
When a person with a disability is afforded the opportunity to acquire the same information, engage in the same interactions, and enjoy the same services as a person without a disability in an equally integrated and equally effective manner, with substantially equivalent ease of use. (U.S. Department of Education, 2013, p. 3)
Physical accessibility includes factors such as ample accessible parking, pathways without stairs, clear curb cuts, even paving, wide doors and pathways, clear signage, clear spaces for wheelchairs and mobility devices, and accessible bathrooms. Accessibility of websites and other digital services is also covered under the ADA. The accessibility of learning management systems, captioning and transcripts for videos, and accessible file types are all important factors in classroom accessibility. Despite the ADA requirements, many spaces fall short, emphasizing the need for continual self-evaluation and consultation (ADA National Network, 2016).
Accessibility is often viewed only as what must be done at a minimum legally, and sometimes it is unclear within a given structure who exactly is responsible for ensuring accessibility. This often results in a reactive approach that places the burden on disabled people to experience barriers and report them. Another common approach is an accommodation mindset, in which disability is seen as so unlikely within a setting that those who need disability supports are seen as burdensome and must request them in advance. This can be contrasted with a barrier reduction or universally designed approach, in which disability would be proactively considered and planned for within a system or space. The resistance to these more equitable approaches is largely the result of lack of awareness of disability prevalence and needs, rooted in ableism and able privilege (Dolmage, 2017).
Able Privilege
Able privilege (also referred to as ability privilege or able-bodied privilege) is a viewpoint in which non-disabled bodies are considered normative. This condition lends itself to the continuation of inaccessible environments and attitudes, which, in turn, further entrenches able privilege within society. To illustrate the implications of able privilege, one may consider the day-to-day experiences of non-disabled individuals and the stark contrast with the experiences of disabled people. The simple act of opening a door without strategizing your approach or having the liberty to choose any seat at a movie theater or concert are further indicators of able privilege. If you have always been able to access materials showcasing individuals of your ability as role models or had access to mentors who mirror your ability, you have experienced able privilege. The ability to move around with the assurance that housing options will generally be accessible to you is a distinct advantage, one that disabled people, particularly those who use mobility devices or who have physical limitations often cannot take for granted. The invisibility of these privileges to those who benefit from them is precisely what fuels the cycle of able privilege, leading to a lack of representation and empowerment for disabled individuals (Dolmage, 2017).
Able privilege is a major but often neglected aspect of social inequality, mostly because disabled individuals are systematically underrepresented. This exclusion is deeply ingrained in our society, impacting policies, cultural norms, and current structures, which further magnify able privilege. “Ugly laws,” a discriminatory legislation active in certain parts of the United States through the ’70s and ’80s, literally pushed disabled people out of public view, further contributing to their erasure (Schweik, 2011). The discomfort with the disabled body being seen and acknowledged in public continues, with organizations like the Ford Foundation finding a lack of disability representation in popular media (Heumann et al., 2019). Despite increasing emphasis on diversity, equity, inclusion, and accessibility (DEIA) in counseling, the reality is that the disability community often finds itself on the outskirts of these crucial conversations because of historical inequalities that are unchallenged or a continued lack of equitable access (Dolmage, 2017).
This cycle of exclusion parallels a common physical accessibility challenge: The lack of disabled people present in a space is often used to justify a lack of priority given to accessibility. However, the inaccessibility itself is the barrier preventing disabled people from entering and remaining in these spaces in the first place. Inaccessibility precludes disabled presence and advocacy, and barriers often then stand unchallenged.
Our educational systems and programs are no exception to the impacts of the exclusion of disabled bodies and minds. Ableist ideologies are often left unchallenged and unknowingly promoted, shaping the understanding of disability at crucial developmental stages. The exposure that most people have to disabilities is also skewed, leading to the formation of harmful stereotypes and stigmas discussed further below.
Disability Culture
Disability culture encompasses a group identity with shared experiences, a history of oppression, literature, art, language, and expression. This is highlighted through various forms of art and literature and through movements advocating for disability rights and inclusion (Brown, 2015). However, the disability community boasts a rich and diverse culture that’s often absent from mainstream media and popular culture.
Representation
As with other minoritized and marginalized populations, the representation of disability in mainstream media, film, and literature can have significant impacts on the societal view of disability and bias and stigma experienced by disabled individuals. Because of the various challenges in access presented by society and the taboos regarding discussions of disability, media is a primary way many people may form opinions about disability and disabled people. Unfortunately, these depictions are few and often convey misinformation and harmful tropes. In a review of 100 top movies in 2016, fewer than 3% of characters had a disability (Smith et al., 2017). Heumann and colleagues (2019) found in their examination of disability in media that most disabled characters in film fell into four stereotypes: the Super Crips who triumph over disability and provide the message that disability is merely a negative thing to be overcome; Villains who are often portrayed with disfigurement of some kind and play on fear and discomfort of disability and difference; Victims who are defined only by their disability and often are shown as better off dead than disabled; or Innocent Fools who embody negative stereotypes of those with intellectual disabilities or neurological differences. These issues with one-dimensional and negative representation in the small number of examples of disability shown on the screen are compounded by a lack of input from disabled writers, actors, or directors. Most disabled characters are played by non-disabled actors, and disability is the most underrepresented minority in the Hollywood film industry (Woodburn & Kopić, 2016).
Within the disability community, a starkly different narrative emerges, often directly hitting back at the misrepresentation and villainization of disability that is commonplace in mainstream media. For example, Disfigured: On Fairy Tales, Disability, and Making Space by Amanda Leduc (2020) critically analyzes the narratives ingrained in our culture around disability. Leduc particularly explores the impact of fairy tales and their modern retellings on identity development and belonging for disabled people, centering her own story and other disabled people’s narratives. Crip Camp, a Netflix documentary, discusses the disability rights movement through the personal stories of advocates such as the late Judy Heumann (Hale & LeBrecht, 2020). Heumann’s autobiography, Being Heumann: An Unrepentant Memoir of a Disability Rights Activist (2020), is a powerful work in the disability space along with early commentaries on empowered language and identity choice such as Nancy Mairs’s essay, On Being a Cripple (1986).
“Crip culture” is one notable aspect of disability culture. In the anthology Criptiques, compiled by Caitlin Wood (2014), crip, slang for cripple, is embraced as a powerful self-descriptor, representing audacity, noncompliance, and a direct challenge to disability being pushed into the shadows. It is an example of the arts and expression of “crip culture,” which draws on shared experiences of ableism, creating a community that affirms and reflects its members’ originality and beauty. Criptiques presents a diverse set of essays embodying this revolutionary spirit and fostering discussions about disability experiences (Wood, 2014).
Social media platforms, particularly X/Twitter, have catalyzed the formation of a global disability community. Hashtags like #DisabledandCute and #AbledsAreWeird have trended, fostering discussions and highlighting the shared experiences within the disability community. “The disability revolution will be tweeted” because of the critical role social media plays in fostering community in accessible formats (Wilson-Beattie, 2018).
Emerging trends in disability spaces include the #SayTheWord movement, which seeks to reclaim the term disability and challenges forced person-first, euphemistic language often pressed on the disability community by able-bodied individuals, discussed further below. Spoonie communities are also prevalent in chronic illness and even some mental health circles. These spaces use the spoon theory by Christine Miserandino (2003), which describes how there is a set amount of energy for daily tasks that can be lowered by disability-related factors such as pain or fatigue. Spoon theory seeks to help disabled people and those close to them understand the fluctuating nature of chronic illness and better communicate about it.
Language and Empowered Expression
It is essential to understand how to talk about disabilities and disabled people in an empowering and inclusive way. Person-first language (e.g., “person with a disability” and “person with [condition]”) emphasizes the person before the disability. While this language is used primarily in academic spaces and was mandatory until the seventh edition of the American Psychological Association style manual (APA; 2020), it is often criticized for being avoidant and contributing to perpetuating rather than confronting stigma (Collier, 2012).
Alternatively, identity-first language proposes that the identity of an individual should lead the conversation. This mode of language is used more commonly within disability spaces, such as “disabled individuals” or “autistic people.” Some subgroups, like the Deaf and autistic communities, strongly identify with their disability factors, promoting a sense of disability pride.
Disabling language, such as “handicapped,” “wheelchair-bound,” or “crippled,” are terms that are outdated, inaccurate, and offensive. These terms can be stigmatizing based on social and historical contexts, like referring to someone diagnosed with schizophrenia as “schizophrenic.” The exception to this is in usages such as those outlined above in which some subcommunities have reclaimed words like “crippled” or find them accurate and therefore identity affirming. This highlights a trend that language and slang within the disability community often focuses on relevant factors of assistive technology or the disabilities themselves (e.g., “wheelies” for wheelchair users, “spoonies” for those who endorse spoon theory, or “potsies” for those with postural orthostatic tachycardic syndrome [POTS]), whereas out-of-group language typically rejected by disabled people is often designed to avoid using the word disability (e.g., “differently abled,” “diverse-ability,” or “special needs”).
While person-first language is valid and should be used when it is the preference of the individual with a disability, there are many compelling arguments for normalizing and empowering identity-based language. Person-first language can be incongruent with people’s self-concept and with their experience of the perception others have of them. Person-first language can perpetuate stigmatization of disability, leading to perceived hypocrisy (Collier, 2012). The language choices made by able-bodied allies often disregard the preferences of the disabled community, echoing a history of erasure and opposing the principle of “nothing about us without us.” This has sometimes extended to able-bodied academics imposing their preference for person-first language on disabled people through academic standards and publishing norms. It can be argued that these restrictions historically have inhibited self-identification, language preference, and the ability to produce scholarship that accurately represents disabled people and community values. This impedes collaborative research with the disability community and reinforces a division and lack of understanding between the disability community and counselors or other medical and mental health providers.
Allyship and Disability Justice
Allyship is not an identity but a practice. Allies for the disability community must operate in solidarity with and advocate for the rights of those oppressed by systems in ways that do not reinforce the system’s oppression (Brown, 2015). This involves actively listening, observing dynamics of power, focusing on impact rather than intent, leaning into discomfort, modeling inclusive language, and offering kind and constructive feedback. In this context, it’s vital to understand ableism, defined as, “a system of assigning value to people’s bodies and minds based on societally constructed ideas of normalcy, productivity, desirability, intelligence, excellence, and fitness” (Lewis, 2022, para. 4). Ableism devalues and discriminates against disabled people and gives preference and normative status to able-bodied people.
The Disability Justice framework (Sins Invalid, 2015) offers a comprehensive and inclusive perspective on human bodies and experiences. The Disability Justice framework was originally developed by the activist Patty Berne, a co-founder of the organization Sins Invalid, to reflect the collaborative work occurring in community spaces. Sins Invalid is a performance project that deconstructs the dehumanizing practices disabled people face and centers intersectionality and diversity of identities.
The Disability Justice framework emphasizes that every body is unique, important, and powerful. This framework understands that people are shaped by complex intersections of factors like ability, race, gender, sexuality, social class, nationality, religion, and more. Instead of isolating these factors, it insists on viewing them collectively. This viewpoint stresses that our pursuit of a fair society is rooted in these intertwined identities and points out a critical observation: Our current global system is essentially “incompatible with life” (Berne, 2015, para. 13). Disability Justice principles include “leadership of the most impacted,” “interdependence,” “collective access,” “cross-disability solidarity,” and “collective liberation” and focus strongly on intersectionality and cross-movement organizing to ensure no one is left behind or excluded (Sins Invalid, 2015, p. 1).
Although there are voices advocating for disability rights, these are predominantly from within the disability community itself, a testament to the lack of understanding and allyship from broader society. Historically, those who could have been allies—abled caregivers, academics, medical professionals, and others—have often worked against the community, whether consciously or not (Dolmage, 2017). This can be combated first by ensuring access to spaces so that disabled voices are present. Then, allies can elevate these voices while implementing a framework like disability justice to ensure that those impacted are leading and that cross-disability approaches are being implemented around equity and liberation work, in line with community priorities.
Implications for the Counseling Profession
Counselor Education and Preparation
Instructors have a critical role in supporting disabled counselors-in-training. Not only is this support mandated by law, but it also increases visibility, representation, and lived experiences of disability in the profession, thereby improving services for clients. Implementing Universal Design for Learning (UDL) can minimize the need for accommodations and provide access, engagement, and learning motivation to the widest possible audience of learners (CAST, 2018). UDL is grounded in Universal Design principles, which are architectural strategies to make physical spaces usable by the widest number of people possible. The UDL principles include strategies such as multiple means of representing information to capture various learning types and multiple means of expression to allow learners to demonstrate learning in various ways (CAST, 2018). Adopting these principles can significantly contribute to making materials and learning environments more accessible. Instructors should consider how they can better focus on curriculum, activities, and assessments that increase exposure of counseling students to disability as a common multicultural factor and client identity. In addition, it is highly advisable to approach accessibility proactively in assignments and course materials and to become comfortable with the process required to swiftly provide equitable accommodations for students when a request is made.
Where a need for access or accommodations is established for a student, an opportunity also exists to proactively advocate for and support students in ensuring accessibility and equity in their practicum and internship placements, graduate assistantships, and other duties required for or connected to their program of study. Sometimes a student’s disability and related accommodation needs are new. Even for those who have established what they need to succeed in a classroom, counseling programs with their clinical requirements are a new setting and students may not always know what they need in advance. It is therefore the responsibility of counselor educators to take a barrier reduction approach, take on the labor of researching the accessibility of approved sites and processes of accommodations specific to graduate students within their universities, and work collaboratively with the student at all stages of a program.
Counseling Practice
It is an ethical mandate that counselors become competent in working with disabled clients as addressed in the ACA Code of Ethics pertaining to nondiscrimination and multicultural issues (American Counseling Association, 2014). It is also important for counselors to work in ways that are respectful and promote client autonomy. This can begin with ensuring that proper etiquette is understood. Examples include speaking directly to a person, not their interpreter or attendant; not drawing attention to, commenting on, or interfering with assistive technology (including service animals); and asking questions rather than making assumptions. Working from a disability-affirming perspective is important, as well as being engaged in self-reflective work around disability bias and seeking appropriate supervision. Supervision might be with a peer to check for bias and process reactions to disability topics, or with someone with disability identity or rehabilitation training to consult on best practices around accessibility and disability-affirming approaches.
The physical counseling environment needs to be accessible according to ADA guidelines, and this should be determined based on the checklist for existing facilities and/or a professional consultant (ADA National Network, 2016). Continuing to offer telehealth as an option while still ensuring spaces are accessible helps to meet a long-standing need expressed by disabled people in ensuring access to mental health care. Websites need to meet web accessibility guidelines, and it is advisable to ensure accessible formats are available for documentation (e.g., large font and digital options). Within spaces, common triggers for various conditions should be considered. For example, fluorescent lights may trigger migraines or neurological conditions, while chemical sensitivities could be triggered by anything from bleach and other cleaning supplies to perfume, room fresheners, or lavender and other essential oils.
In working with clients, it should not be assumed a client is not disabled merely because they are not visibly disabled or have not disclosed a disability. If a client is visibly disabled or has disclosed but not elaborated, signaling openness to further discussion while respecting boundaries and client priorities is warranted. Intrusive questioning is never appropriate, and client autonomy and treatment goals should always be respected. In my own work, I think of this similarly to when I may diffuse a question regarding trauma on an intake by acknowledging the client may not yet trust me; we can come back to discuss it further at any time in our work together, and I invite them to share to their level of comfort. An example of broaching a visible or previously disclosed disability might be simply asking if there is anything that can be done to increase accessibility or comfort in the space. Another approach might be to reflect the client’s own language to describe the disability, chronic illness, assistive technology, etc. and to simply ask if there is anything specific that the client would like for you to know up front that would support your work together, or whether they would like to address things as they come up.
Conclusion
Disability culture is rich and complex, asserting its place in sharp contrast to mainstream narratives with defiance. It is a culture that celebrates wholeness and intersectionality and challenges ableist norms without apology for occupying space.
By understanding how ableism in counseling and counselor education fits into the broader history of disability oppression and increasing awareness of disability culture and disability justice, the counseling profession can better serve the disability community. Normalizing conversation about disability allows us to prepare ourselves, our students, and our supervisees to work with this large and diverse population. When we act intentionally to proactively make spaces accessible, we are providing disabled people with the same rights we provide to other clients. This allows them to share their stories gradually and comfortably, without having to disclose too early or fight for their basic rights.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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K. Lynn Pierce, PhD, NCC, ACS, LPC, CRC, is an assistant professor and Counselor Education and Supervision PhD Program Coordinator at Mercer University. Correspondence may be addressed to K. Lynn Pierce, Mercer University College of Professional Advancement, 2930 Flowers Rd. S., Chamblee, GA 30341, pierce_k03@mercer.edu.
May 10, 2023 | Volume 13 - Issue 1
Warren Wright, Jennifer Hatchett Stover, Kathleen Brown-Rice
Racial trauma has become a common topic of discussion in professional counseling. This concept is also known as race-based traumatic stress, and it addresses how racially motivated incidents impede emotional and mental health for Black, Indigenous, and people of color (BIPOC). Research about this topic and strategies to reduce its impact are substantial in the field of psychology. However, little research about racial trauma has been published in the counseling literature. The intent of this paper is to provide an in-depth perspective of racial trauma and its impact on BIPOC to enhance professional counselors’ understanding. Strategies for professional counselors to integrate into their clinical practice are provided. In addition, implications for counselor supervisors and educators are also provided.
Keywords: racial trauma, BIPOC, counseling, professional counselors, clinical practice
The impact of racism on the psychological, emotional, and physical well-being of those subjected to it is no secret. In fact, the Centers for Disease Control and Prevention (2021) has declared racism as a public health issue and threat to the health of minoritized individuals. Similarly, the Federal Bureau of Investigation (2019) reported that 5,155 people were targets of racially motivated hate crimes in 2018: 47.1% of the victims identified as Black/African American, 13% as Hispanic/Latino, 4.1% as American Indian/Alaskan Native, and 3.4% as Asian. Daily experiences of racism for Black, Indigenous, and people of color (BIPOC) can lead to an increase in health complications and mental health disparities (French et al., 2020; Williams et al., 2019). Hemmings and Evans (2018) noted that because of racism, BIPOC communities have limited access to resources, which impacts their quality of education and health care. Thus, racially marginalized communities are susceptible to chronic illnesses and mental health concerns such as diabetes, heart disease, depression, and suicide (Hemmings & Evans, 2018). Furthermore, researchers have found that exposure to racism and discrimination increases levels of stress in the body and can lead to chronic illnesses such as high blood pressure, diabetes, and gastrointestinal issues for people of color (Bernier et al., 2021; Chavez-Dueñas et al., 2019; Smith et al., 2011; Wagner et al., 2015), therefore adversely impacting the livelihood and overall well-being of BIPOC communities.
Racism-related stressors can lead to race-based traumatic stress, also known as racial trauma (Carter, 2007; Comas-Díaz et al., 2019). Racial trauma and race-based traumatic stress occur when there is an experience of direct or indirect racism that leads to psychological and emotional injury for BIPOC. Examples include experiencing microaggressions in the workplace (Sue et al., 2019), witnessing an unarmed Black person being killed by law enforcement (Williams et al., 2018), and being physically attacked because others believe a person’s racialized group is the cause of a global pandemic (e.g., Asian American and Pacific Islanders [AAPIs]; Litam, 2020). There is a substantial amount of literature in the field of psychology related to racism, race-based traumatic stress, and racial trauma (Adames et al., 2023; Bryant-Davis & Ocampo, 2006; Carter, 2007; Comas-Díaz et al., 2019; French et al., 2020; Helms et al., 2010; Mosley et al., 2021). However, there is little to no research in the counseling profession related to racial trauma. Therefore, this article provides an overview of racial trauma and implications for the counseling profession.
Race-Based Traumatic Stress and Racial Trauma
Racial trauma is the collective stress experienced by BIPOC directly or indirectly due to continuous racially motivated incidents of microaggressions, exclusion, discrimination, and sociopolitical events that create psychological and emotional harm (Anderson & Stevenson, 2019; Comas-Díaz et al., 2019). Race-based traumatic stress is one of the most common interchangeable terms for racial trauma and refers to the stress response and emotional injury that occur after experiencing a racist encounter (Carter, 2007; Williams et al., 2018). Carter (2007), along with other researchers (Chavez-Dueñas et al., 2019; Helms et al., 2010; Smith et al., 2007, 2016), examined the experiences of BIPOC and the accompanying psychological stress when they experience racism-related incidents. Constant exposure to racially motivated incidents can create and lead to an overwhelming emotional stress response for BIPOC. Bryant-Davis and Ocampo (2005), Hemmings and Evans (2018), and Litam (2020) discussed how racist incidents of physical assaults, verbal attacks, and threats to one’s safety impact a person’s sense of self and can cause a person to present with symptoms of trauma.
It is imperative to note that experiencing racism and presentation of trauma symptoms are not all life threatening. Therefore, racial trauma differs from the traditional diagnosable PTSD criteria as stated in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013). Although it is not explicitly stated in the DSM-5, racial trauma encompasses racism-related stressors associated with one’s membership in a racialized social group, historical trauma, and continuous exposure to racism-related violence. Consequently, conceptualizing and diagnosing a client that presents to counseling with trauma symptomology that does not fit the criteria for the PTSD diagnosis can be confusing for mental health professionals. Therefore, it is important for professional mental health counselors to be prepared to assess and treat clients who present to counseling with trauma symptomology related to racist incidents.
Impact of Racism and Racial Trauma
Racial trauma could impact a person’s sense of self, pride in culture, and identity (Brown-Rice, 2013; Skewes & Blume, 2019). Skewes and Blume (2019) found that assimilation, exploitation, and forced relocation led to the loss of spiritual and cultural practices for American Indian and Alaska Native (AI/AN) communities. Additionally, Brown-Rice (2013) stated that loss of cultural traditions and native practices creates a sense of confusion and hopelessness for Native American adults. Thus, racialized trauma can lead to a separation of cultural identity and practices. Similarly, Chavez-Dueñas and colleagues (2019) found that racial trauma has increased psychological distress for Latinx immigrant communities because of anti-immigration policies, opposition to assimilation into the American culture, and fear of deportation. Furthermore, racial trauma can lead to psychological concerns such as anxiety, depression, emotional dysregulation, and suicidal ideation (American Foundation for Suicide Prevention, 2020; Bryant-Davis & Ocampo, 2005; Comas-Díaz et al., 2019; French et al., 2020; Hemmings & Evans, 2018). Additionally, the American Foundation for Suicide Prevention (2020) found suicide rates for minoritized communities have increased. Moreover, racial discrimination has been positively correlated with suicidal ideation among African American young adults (American Foundation for Suicide Prevention, 2020).
Racism is consistently prevalent within American schools and continues to be an issue of concern experienced by BIPOC students (Kohli et al., 2017; Merlin, 2017). The experience of trauma coupled with racism and discriminatory practices in education has shown to impart racial disparities among BIPOC students in the areas of academic achievement, employment, and participation in the criminal justice system (Lebron et al., 2015). Black students are underrepresented in advanced courses, are less likely to be college ready, and spend less time in the classroom because of disciplinary practices (United Negro College Fund, 2020). According to a report on school discipline by the U.S. Department of Education Office for Civil Rights (2018), Black students only account for 18% of preschool enrollment, yet they make up 42% of total suspensions and 3 times more expulsions than their White peers. In addition, Black students are more than twice as likely to be referred to law enforcement and subject to arrest for school-based incidents when compared to their peers (United Negro College Fund, 2020). Furthermore, not only are Black students underrepresented in advanced courses, but they are overrepresented in special education programs and more likely to be identified with a disability (Harper, 2017). Therefore, it is imperative for professional mental health counselors to understand how racial trauma could impact the mental health and well-being of individuals at distinct phases of life span development (e.g., children, college students, etc.).
Currently, racial trauma has been exacerbated by the recent COVID-19 pandemic plaguing the United States and other parts of the world. Liu and Modir (2020) and Fortuna et al. (2020) highlighted the lived experiences within BIPOC communities regarding living in low-income neighborhoods, denial of access to care, and being disproportionately affected by the COVID-19 virus. Black Americans accounted for 34% of confirmed cases in the United States, followed by Latinos at 20%–25% of cases (Fortuna et al., 2020). This demonstrates that health disparities coupled with racism could impact the physical well-being of BIPOC. Racism-related stress impacts the emotional and physical health of BIPOC communities. This includes sense of self (Chavez-Dueñas et al., 2019), culture identity (Skewes & Blume, 2019), and overall wellness (Litam, 2020). Healing racial trauma requires professional mental health counselors working with BIPOC individuals to consider sociocultural factors such as systemic racism, oppression of marginalized communities, and cultural trauma.
Implications for Professional Counselors
The counseling profession highlights the importance of assessment competency as stated in the American Counseling Association (ACA) Code of Ethics (ACA, 2014; e.g., Standard E.5.c: Historical and Social Prejudices in the Diagnosis of Pathology) and the 2016 Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2015) Standards (e.g., Assessment and Testing). In addition, the 2016 CACREP standards emphasized the importance of social and cultural diversity, highlighting strategies and techniques to identify and eliminate barriers of oppression and discrimination (CACREP, 2015). Because racial trauma is invasive and harmful for BIPOC individuals and communities, understanding its impact on psychological and emotional well-being is imperative for all mental health professionals in their respective roles. Thus, counselors must be prepared to provide culturally responsive care to BIPOC individuals who have experienced racism-related trauma.
Licensed Professional Mental Health Counselors
Assessing for racial trauma is of utmost importance when conceptualizing and creating a treatment plan for BIPOC clients. It is imperative for counselors to become familiar with assessments and clinical interventions to inform their approach to treating racial trauma. Williams and colleagues (2018) proposed the UConn Racial/Ethnic Stress and Trauma Survey (UnRESTS) to assist mental health professionals in their case conceptualizations and treatment planning when racial trauma is present in BIPOC individuals. The UnRESTS is a clinician-administered semi-structured interview that is beneficial in case conceptualization to determine the multiple experiences of racism for the client. The interview comprises 6 sections: introduction of the interview, racial and ethnic identity development, experiences of direct overt racism, experiences of racism by loved ones, experiences of vicarious racism, and experiences of covert racism (Williams et al., 2018). Even though this survey is like the DSM-5 Cultural Formulations Interview (APA, 2013) and helps the counselor determine if the client’s symptomology fits criteria for PTSD, it should not be the only assessment tool used to determine a diagnosis of PTSD. Additionally, this interview tends to be lengthy in time; therefore, counselors should consider completing this interview within the first and second sessions. This assessment along with other clinical approaches could be beneficial to understanding the traumatic responses of clients impacted by racism.
Several BIPOC scholars have offered models, theories, and frameworks to heal racial trauma (Adames et al., 2023; Bryant-Davis & Ocampo, 2006; French et al., 2020; Mosley et al., 2021). Counselors must position themselves to consider approaches that go beyond Eurocentric theories and models when addressing and treating racial trauma. These include being critical of sociopolitical structures, awareness of one’s own racial identity, and comfort level when broaching the topic of racism and racial trauma (Adames et al., 2023; Thrower et al., 2020). For instance, Bryant-Davis and Ocampo (2006) provided a foundation for treating racial trauma in a safe environment. Their therapeutic approach included acknowledgment, grieving/mourning loss, analyzing internalized shame and racism, and centering coping and resistance strategies. Supporting clients to name oppressive systems, process their experiences of racist incidents, and deconstruct self-blame narratives because of racism fosters liberation and healing for BIPOC clients who have experienced racism-related stress and trauma (Adames et al., 2023). Thus, counselors must be empathetic and take initiative in helping BIPOC clients shift the focus on harm from self-blame to external oppressive factors. This promotes a strong sense of self and healthy living for BIPOC clients.
Similarly, models offered by Chavez-Dueñas et al. (2019), French et al. (2020), Mosley et al. (2021), and Adames et al. (2023) center the well-being and collective power of BIPOC communities. For example, critical consciousness, Black Psychology, Liberation Psychology, and trauma-informed care influenced these approaches to address racism-related stress and trauma. Subsequently, French and colleagues’ (2020) Radical Healing Framework centers justice and overall wellness for BIPOC communities. This is the intentional practice of going beyond just coping with racism to focus on healing wherein a client can thrive by connecting to community and engaging in resistance against racism-related stressors (French et al., 2020). Thus, helping clients to engage in activism and utilize microinterventions to disarm and address microaggressions can empower clients (Mosley et al., 2021; Sue et al., 2019). Microinterventions help equip clients with tools they can implement to assert boundaries and communicate disagreement with microaggressions (Litam, 2020; Sue et al., 2019). However, counselors must remember that safety is a priority when supporting clients in confronting perpetrators of racism-related trauma (Litam, 2020). Therefore, role-plays in counseling sessions could provide the space and time to strategize when it is and is not appropriate to confront perpetrators of microaggressions.
Utilizing these approaches with clients fosters validation and affirmation of their experiences. Failure to acknowledge and attend to the symptoms and experiences of racism-related stress and trauma can maintain psychological distress for BIPOC clients (Chavez-Dueñas et al., 2019). Furthermore, helping clients process the positive messages they received about their racial identity throughout their life can reinforce these approaches (Anderson & Stevenson, 2019). Thus, counselors should use a strength-based approach when supporting BIPOC clients in healing from racism-related stress and trauma. In addition, consultation with colleagues, supervisors, and counselor educators can provide support and a space to implement best practices to provide the most effective care for BIPOC individuals who have experienced racial trauma, rendering positive mental health outcomes.
Professional School Counselors
Professional school counselors should demonstrate cultural competence and serve as essential stakeholders in identifying and supporting clients impacted by trauma (ACA, 2014; American School Counselor Association [ASCA], 2016; Parikh-Foxx et al., 2020). ASCA specifies these responsibilities and obligations in their ASCA Ethical Standards for School Counselors (ASCA, 2022). These principles serve as a framework in which professional values, norms, and behaviors are referenced. Further, school counselors can help to identify, respond to, and prevent incidents of racism and bias, as well as become resources to help promote systemic change and advocate for social justice within the educational setting (ASCA, 2020). However, ASCA (2021) recognizes the lack of racial literacy and the inherent gaps between racial equity and equality within education, petitioning for school counselors to continually pursue cultural competency and work toward mitigating the negative effects of racism and bias. Subsequently, ASCA guidelines encourage school counselors to examine their own biases and consult with community professionals to engage in immersive experiences and provide support to students and families who have experienced racial trauma or have been negatively impacted by racism (ASCA, 2021; Atkins & Oglesby, 2019; Levy & Adjapong, 2020).
As facilitators of change, school counselors can help to create environments that are safe and inclusive for both students and educators. One approach is to discuss issues of racial trauma using trauma-informed and restorative practices (National Child Traumatic Stress Network [NCTSN], 2018). Trauma-informed practices take on a phenomenological approach, seeking to identify, understand, and address the meaning behind student behaviors and experiences (Steane, 2019). Additionally, restorative practices not only provide an alternative to harsh disciplinary practices, but also create spaces for individuals to share their own perspectives without fear of judgement or ridicule, while being open to listening and validating the values, experiences, and perspectives of others (NCTSN, 2018; United Negro College Fund, 2020). Moreover, Anderson and Stevenson (2019) posited the concept of racial socialization, which is the intentional communication about the system of racism, racial identity, and experiences between parents and their children and others within the family system with similar racial and ethnic identities. Racial socialization aids in the development of a positive sense of self and cultural identity as mitigating forces to racial trauma. Further, the Racial Encounter Coping Appraisal and Socialization Theory (RECAST) helps families and youth prepare for, discuss, and respond to racially stressful experiences appropriately (Anderson & Stevenson, 2019). Thus, this can also prepare students to strategize how to respond to incidents of racism in the school environment.
It is evident that incidents of school-based racism are perpetuated by several factors and continue to negatively impact student performance and affect the health and well-being of BIPOC students (Kohli et al., 2017). The implementation of culturally responsive pedagogy can be used to mitigate this impact, increase academic success, and help students maintain cultural integrity (Ladson-Billings, 1995; Lebron et al., 2015). Counseling professionals can support this effort by engaging in training and professional development to understand racism and its impact on culturally diverse students and by facilitating necessary discussions that help to equip stakeholders with tools to adequately address discrimination, racism, and race-based trauma (NCTSN, 2018; Pietrantoni, 2017).
Counselor Supervisors
The ACA Code of Ethics (2014; e.g., Section F: Supervision, Teaching, and Training) highlights the importance of counselor supervision for the development of counselors seeking licensure as independent mental health practitioners. Additionally, counselor supervision enhances a supervisee’s knowledge, skills, and ability to work with diverse clients (ACA, 2014). Therefore, counselor supervisors and their supervisees should be aware of racial trauma and the effects it could have on BIPOC clients. Pieterse (2018) posited guidelines and considerations for supervisors to follow when attending to racial trauma concerns in clinical supervision. Specifically, supervisors must be reflective of their own racial identity, understand how to assess for racial trauma, and implement effective clinical interventions for their supervisees’ clients impacted by racial trauma (Pieterse, 2018).
Additionally, understanding the concept of racial trauma in the larger context of historical trauma for BIPOC communities creates a learning environment for supervisees to deepen their knowledge of racial trauma (Comas-Díaz, 2000; French et al., 2020; Pieterse, 2018). For example, educating supervisees on historical depictions of racism-related stress and trauma for BIPOC communities, such as internment camps, chattel slavery, and colonization, provides the historical context of psychological wounds impacting BIPOC communities in present day by way of intergenerational trauma (Comas-Díaz et al., 2019; Nagata et al., 2019). Furthermore, clinical supervisors can role-play in supervision meetings with their supervisees to model helping clients process racist-related incidents, assessing for psychological distress, and empowering clients to practice effective coping and resistant strategies (Pieterse, 2018), thus ensuring supervisors’ awareness of multiculturalism and diversity in the supervisory relationship (ACA, 2014; e.g., Section F.2.b.: Multicultural Issues/Diversity in Supervision). It is critical for counselor supervisors to obtain the knowledge, skills, and abilities to best prepare counselor supervisees in addressing and treating racial trauma concerns.
Counselor Educators
Moh and Sperandio (2022) urged the counseling profession to integrate trauma-informed curricula to best prepare counselors-in-training (CITs) to respond effectively to trauma concerns caused by systemic racism in the United States. However, there is hesitancy for counselor educators to teach CITs about racial trauma (VanAusdale & Swank, 2020). Specifically, counselor educators have reported a lack of knowledge and limited ability to teach CITs about racial trauma (VanAusdale & Swank, 2020), futher highlighting the need for trauma-informed curricula to be adopted in the counselor profession to best prepare counselors and educators to address the needs of those impacted by racial trauma. In addition, counselor educators’ lack of knowledge in trauma-informed care and racial trauma does not help prepare future CITs to address this concern once they have graduated from their respective counselor education programs, consequently leading to racial trauma concerns going unaddressed and deepening the wounds of racial trauma for BIPOC (Bryant-Davis & Ocampo, 2005; Comas-Díaz, 2000; Helms, et al., 2010).
However, counselor educators can find creative ways to implement racial trauma education into the classroom. For example, counselor educators can include required readings from BIPOC scholars in their classes that contribute to the racial trauma literature (e.g., Anderson & Stevenson, 2019; French et al., 2020; Mosley et al., 2021). Additionally, counselor educators can demonstrate how to implement the UnRESTS (Williams et al., 2018) for CITs in practicum and internship courses who are practicing conducting clinical interviews. Furthermore, counselor educators can introduce CITs to theories that go beyond the Eurocentric tradition. For example, the first author of this article, Warren Wright, was introduced to queer theory, critical theory, and critical race theory in his master’s-level multicultural counseling (formerly cross-cultural counseling) course. As a student, Wright was assigned to write a social justice and advocacy paper, in which he utilized critical race theory to discuss how adolescents’ responses to experiencing racism in K–12 education could present as behavioral and emotional dysregulation. To mitigate this concern, Wright created an after-school program that utilized dance movement therapy (i.e., stepping) to help Black adolescent males with emotional regulation, personal development, and academic excellence. This approach is an example of a trauma-informed and responsive practice that could reduce harsh disciplinary referrals and increase Black students’ socioemotional development (Stover et al., 2022). If counselor educators feel inadequate to teach trauma counseling or trauma-informed practices, they should seek additional training and consultation to increase their awareness, knowledge, and skills about trauma-informed curricula and approaches (Moh & Sperandio, 2022).
Conclusion
The aim of this article is to provide an understanding of racial trauma and its impact on the psychological and emotional well-being of BIPOC communities and provide recommendations for the counseling profession. Intentional practices, strategies, and approaches are needed to help reduce the impact of racial trauma experienced by BIPOC individuals and communities. Therefore, it is imperative for CITs, licensed professional mental health counselors, school counselors, counselor educators, and supervisors to be well-equipped to address racial trauma concerns. Failure of the counseling profession to address racial trauma concerns deepens the psychological and emotional injuries of racial trauma. Therefore, curricula for CITs should be adapted to best prepare the next generation of counselors to aid with and mitigate the lasting impacts of racially motivated trauma inflicted on BIPOC individuals and communities.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Warren Wright, MEd, NCC, LPC, CCTP, is a doctoral student at Sam Houston State University. Jennifer Hatchett Stover, MA, NCC, LPC, CCTP, CSC, is a doctoral student at Sam Houston State University. Kathleen Brown-Rice, PhD, NCC, ACS, LPC, LCMHC, LCAS, is a professor at Sam Houston State University. Correspondence may be addressed to Warren Wright 1932 Bobby K. Marks Drive, Huntsville, TX 77340, wbw007@shsu.edu.
