The State of Integrated Primary and Behavioral Health Care Research in Counselor Education: A Review of Counseling Journals

Alexander M. Fields, Cara M. Thompson, Kara M. Schneider, Lucas M. Perez, Kaitlyn Reaves, Kathryn Linich, Dodie Limberg

The integration of behavioral health care within primary care settings, otherwise known as integrated care, has emerged as a treatment modality for counselors to reach a wide range of clients. However, previous counseling scholars have noted the lack of integrated care representation in counseling journals. In this scoping review, we identified 27 articles within counseling journals that provide integrated care implications. These articles appeared in 10 unique counseling journals, and the publication years ranged from 2004–2023. Articles were classified as: (a) conceptual, (b) empirical, or (c) meta-analyses and systematic reviews. The data extracted from the articles focused on the implications for integrated care training and practice for the next generation of counselors, evidence-based treatment approaches, and future research directions.

Keywords: integrated care, counseling journals, scoping review, implications, research

 

One in five U.S. adults are living with a mental illness or substance use disorder (e.g., major depressive disorder, generalized anxiety disorder, alcohol use disorder, nicotine use disorder) and individuals with a mental illness or substance use disorder are more likely to have a chronic health condition (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021). Integrated primary and behavioral health, also termed integrated care (IC), has emerged as a noted treatment strategy to meet the holistic needs of individuals with comorbid mental and physical health symptoms. Although IC has been operationalized inconsistently by scholars, most definitions describe the integration and coordination of behavioral health services within primary care settings (Giese & Waugh, 2017). The SAMHSA-HRSA (Health Resources and Services Administration) Center for Integrated Health Solutions expanded upon this definition to outline IC on a continuum of health care service delivery (Heath et al., 2013). Heath and colleagues described the progressive movement toward IC as (a) collaborative care: providers from multiple health care professions collaborating on holistic health care treatment planning at a distance;
(b) co-located care: providers from multiple health care professions sharing basic system integration, such as sharing physical proximity and more frequent collaboration; and (c) IC: providers from multiple health care professions having systematic integration (i.e., sharing electronic medical records and office space) and a high level of collaboration resulting in a unified treatment approach. Thus, health care consumers are able to receive care for their behavioral and physical health at the same time and location when an IC approach is applied, which may reduce barriers (e.g., transportation, child care, time off work) and increase access to behavioral health care (Vogel et al., 2014).

Beyond support from SAMHSA and HRSA, the IC movement has been endorsed through government legislation. The Patient Protection and Affordable Care Act (2010) paved the way for agencies and health care systems demonstrating an IC approach to receive additional funding for health care providers, as well as increased reimbursements for the services they deliver. Furthermore, the federal government has recently pledged to double the funding support for IC to be more accessible in hospitals, substance abuse treatment facilities, family care practices, school systems, and other health care settings (The White House, 2022). This may be the result of IC showing efficacy in reducing mental health symptoms (Lenz et al., 2018), saving health care expenditures (Basu et al., 2017), and promoting overall life satisfaction (Gerrity, 2016). Compared to traditional (i.e., siloed) care, IC involves simultaneous treatment from physical and mental health providers, thus providing additional access to mental health screenings and services. For example, McCall et al. (2022) concluded that a mental health counselor in an IC setting may support treatment engagement and reduce health care costs for an individual with a substance use disorder when utilizing the screening, brief intervention, and referral to treatment (SBIRT) model. However, the IC paradigm is not a novel concept; Aitken and Curtis (2004) introduced IC to counseling journals by providing emerging evidence of IC support and advocating for health care settings to recognize counselors as an asset to IC teams and for counselors to be trained in IC.

Brubaker and La Guardia (2020) noted that the Council for Accreditation of Counseling and Related Educational Programs (Section 5, Standard C.3.d; CACREP; 2015) required IC education in counselor-in-training (CIT) development. Additionally, the 2024 CACREP Task Force has also included these standards for its proposed revisions (CACREP, 2022). HRSA has funded counselor education programs to train CITs during practicum and internship experiences, funding over 4,000 new school, addiction, or mental health counselors during 2014–2022 through the Behavioral Health Workforce and Education Training (BHWET) Program (HRSA, 2022). Although IC training, education, and practice is occurring within counselor education, IC literature remains scarce in counseling journals (Fields et al., 2023). The lack of representation presents an issue for appropriate training for CITs and future research directions, which leads to sustainability concerns. Specifically, Fields et al. (2023) reported that a lack of IC literature in counseling journals creates a weak foundation to advocate for counselors to be included in the IC movement. With the understanding that nearly half of U.S. adults with poor mental health receive their mental health care in a primary care setting (Petterson et al., 2014), counselors may increase their access to additional clients when they are invited to IC settings. Furthermore, it weakens counselors’ professional identity if counselors are not trained in a standardized approach. As such, this scoping review aims to amalgamate current IC literature within counseling journals and provide CITs, counselors, and counselor educators from diverse backgrounds with a resource to inform their education, practice, and scholarship. The guiding research question for this review is: What are the publication trends (i.e., publication years and journals), study characteristics and outcomes, implications, and recommendations for future research from IC literature within counseling journals?

Method

We conducted a scoping review to identify the publication trends, key characteristics of IC studies (i.e., type of article and study outcomes), and implications for future research of IC literature published in counseling journals (Munn et al., 2018). Our methodology followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews; Tricco et al., 2018) checklist to 1) establish eligibility, 2) identify sources of information, 3) conduct a screening process to select included articles, 4) identify and chart data items, 5) conduct a critical appraisal of included articles, and 6) synthesize results. We searched the following databases for eligible literature: (a) Alt HealthWatch, (b) APA PsycArticles, (c) APA PsycInfo, (d) Education Source, (e) EBSCOHost, (f) Health Source: Consumer Edition, (g) Health Source: Nursing/Academic Edition, (h) MEDLINE with Full Text, (i) Science Reference Center, (j) Social Sciences Full Text (H.W. Wilson), and (k) Social Work Abstracts. We used the search terms: “Integrat* care” OR “integrat* primary and behavioral healthcare” OR “integrat* primary and behavioral care” AND “counsel* education” OR “counsel*.” Additional criteria for this search were full-text, peer-reviewed journal articles, and an English translation.

Eligibility Criteria
     Eligibility criteria for articles included in this review are publication in a counseling journal, presentation of implications (i.e., recommendations for training and evidence-based counseling models or approaches) of IC practice for CITs and counselors through research methodology or conceptual themes, and discussion of future research on IC for counselor educators and counseling scholars through research methodology or conceptual themes. Eligible counseling journals included those published by divisions of the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), the American School Counselor Association (ASCA), the National Board for Certified Counselors (NBCC), and Chi Sigma Iota. Journals connected to international and regional divisions were also included. The initial database search resulted in 222 articles, which we reduced to 125 articles after removing duplicates. Another two articles were identified through additional sources. These additional sources included references identified through a review of an article and a social media post advertising an IC article. We reviewed titles and abstracts for inclusion criteria. This resulted in 28 articles that were fully reviewed. Research team members independently examined articles to summarize information relevant to the research question. During this process, articles were excluded if they did not provide future implications for IC in counseling or counselor education. Following this process, 27 articles were included. A visual representation of the eligibility and inclusion process can be found in Figure 1.

Data Extraction
     After consensus was reached on the final 27 articles, our research team assessed the available evidence and synthesized the results. The seven-member research team comprised four doctoral students in counselor education, an undergraduate student minoring in counselor education, a clinical assistant professor in a counselor education program, and an associate professor in a counselor education program. The initial data extraction process began with identifying journal representation and organizing articles based on similar characteristics. This resulted in classifying articles as either (a) conceptual, (b) empirical, or (c) meta-analyses and systematic reviews. Conceptual articles provided an overview of available literature and identified a current gap in IC understanding for counseling or counselor education. Articles classified as conceptual did not present original data or follow research methodology. Moreover, the conceptual models typically advocated for increased counseling representation in IC settings to reach traditionally underserved groups (e.g., LGBTQ+ clients, individuals from rural communities) or a replicable model of training grounded in empirical support to prepare CITs to work in IC settings. Data from these articles were presented in accordance with the authors’ population(s) of interest, the identified research gap, implications gathered from existing literature, and recommendations for future research. Empirical articles introduced a novel research question and presented results to address that question. Data from these articles were presented in accordance with the authors’ study classification (i.e., qualitative, quantitative, or mixed methods), research methodology, the number and profile of participants, research of interest, and results from their analyses. Lastly, meta-analyses and systematic reviews organized previous empirical studies and presented big picture results across multiple studies. Data from these articles were presented in accordance with the authors’ article classification (i.e., meta-analysis or systematic review), population of interest, number of included studies and number of total participants (if applicable), results, and implications for future research. Because of the broad scope and exploratory nature of this review, a quality assessment was not performed.

Figure 1
Integrated Care Literature in Counseling and Counselor Education Flow Chart

Note. This flow chart outlines the PRISMA-ScR (Tricco et al., 2018) search process.

 

Results

This scoping review resulted in a wide variety of articles in counseling journals that may inform the future of IC research in counseling and counselor education. Additionally, articles included in our review have ranging implications at the CIT, counselor, and client levels. The results section will begin with an overview of IC publication trends within counseling journals, detailing the publication range and specific journals. Next, results for this review were organized based on study outcomes and the classification of the article. The study outcomes sections will further detail included articles that are conceptual, empirical, or meta-analyses and systematic reviews.

Publication Trends
     Articles included in this review range in publication year from 2004–2023. Articles are represented in 10 unique journals. Specifically, the following journals are represented in this review: (a) Counseling Outcome Research and Evaluation (n = 2); (b) International Journal for the Advancement of Counselling (n = 2); (c) Journal of Addictions & Offender Counseling (n = 2); (d) Journal of College Counseling (n = 1); (e) Journal of Counseling & Development (n = 7); (f) Journal of Creativity in Mental Health (n = 1); (g) Journal of LGBTQ Issues in Counseling (n = 1); (h) Journal of Mental Health Counseling (n = 9); (i) The Family Journal (n = 1); and (j) The Professional Counselor (n = 1).

Study Outcomes
Conceptual Articles
     Our review included 11 conceptual articles (see Appendix A). Of these studies, five described IC as a treatment approach for underserved populations. In each of these articles, the authors described how IC provided a “one-stop-shop” treatment approach that provided increased access to a mental health provider in a traditional primary care setting, which reduced barriers to transportation, cost per service, and provider shortages. Six studies focused on current licensed counselors in primary care settings, counselor educators, CITs in a CACREP-accredited program, and counselors interested in IC. Common implications of these articles included advocacy, education, communication, networking, and teamwork.

Eight studies described how additional research could empirically investigate their IC model. The authors of these conceptual articles recommended continued investigation of the current medical model and national recognition of gaps of care for both the chronic pain and substance abuse population; integrating the interprofessional education collaborative (IPEC) into the curriculum of mental health counselors; interprofessional telehealth collaboration (IPTC) through cognitive behavioral therapy (CBT) for rural communities; treatments aligned with cultural tailoring; implementation of IC for those in the LGBTQ+ community; trauma-informed IC; and the role of counselors in an IC team treating obesity. The conceptual models reported in Table 1 highlight evidence-based approaches a counselor can apply in IC settings to assess for substance abuse and mental health disorders, brief interventions (e.g., CBT technique of challenging automatic thoughts, motivational interviewing) to encourage engagement in preventative health care, and trauma-informed practices (e.g., psychoeducation on trauma somatization). Moreover, counselors trained in the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016) can advocate for culturally tailored interventions to respect a client’s cultural identity.

Two studies highlighted different approaches to IC. Johnson and Mahan (2020) identified the IPTC model, which allows health professionals to use technology to increase access to services for rural communities. The IPTC model provides telehealth services to rural communities through an IC model to reduce negative social determinants of health, such as distance from a mental health provider. Specifically, Johnson and Mahan (2020) detailed their approach to working alongside primary care providers to deliver family counseling services and coordinate health care services to promote overall health and wellness for family systems. Goals of their family counseling sessions included increasing health literacy, enhancing a family’s coping strategies for medical conditions, and reducing family conflicts. The Chronic Care Model has been shown to improve the quality of care for clients with chronic medical conditions by increasing communication between health care professionals (Sheesley, 2016). Two articles also focused on the impact of two identified training programs. Johnson and Freeman (2014) identified the IPEC Expert Panel and their efforts to effectively train health professionals to collaborate. Lloyd-Hazlett et al. (2020) focused on the Program for the Integrated Training of Counselors in Behavioral Health (PITCH), which is a training program for master’s-level counseling students in a CACREP-accredited program aimed at training students to supply IC to rural, vulnerable, and underserved communities. These results are represented in Appendix A.

Empirical Articles
     Our review resulted in 13 empirical studies using the following designs: three mixed-methods designs, three quasi-experimental designs, two cross-sectional surveys, two pre-post designs, three phenomenological studies, and one exploratory cross-case synthesis. The studies were completed in a variety of settings, such as university clinics, trauma centers, and hospitals. Participant profiles varied across studies, with nine representing CITs or practicing counselors, three representing clients, and one representing both. In addition to counselors, studies with client-level data included service providers and undergraduate students from social work, speech–language pathology, dental hygiene, nursing, and physical therapy programs. Articles that reported client-level data tested an intervention (e.g., motivational interviewing in an IC setting for a substance use disorder), compared an IC approach to treatment as usual (TAU) in silos, or explored relationships between health care indicators and client engagement in a setting applying an IC modality. Furthermore, three studies in this article used Heath et al.’s (2013) conceptualization of IC, which was the most common model cited.

Most study outcomes were reported as positive benefits for IC. For CIT and counselor-level studies, six described a theme of increased ability and desirability to work with a collaborative approach on IC teams. Participants also commonly reported an increase in professional identity and self-efficacy. Participants in studies by Agaskar et al. (2021), Alvarez et al. (2014), and Lenz and Watson (2023) further demonstrated that working with underserved populations in IC settings increased their multicultural competence, specifically around areas of acceptance, advocacy, and awareness. A gap in IC awareness among service providers and organizational constraints were noted as potential barriers to IC care. Johnson et al. (2021) found interprofessional supervision as a potential barrier to remaining within a provider’s scope of practice, because a supervisor providing supervision to a supervisee from a different professional identity may not appropriately understand roles and responsibilities. Because of this, Johnson and colleagues noted implications for future research and graduate-level training in the classroom and field experience. All four of the studies completed with client-level data were quantitative, accounting for 2,378 client participants. Results of these studies suggested improvement in holistic client functioning (i.e., reduction in pathological symptoms and increase in preventative behaviors; Ulupinar et al., 2021), a decrease in crisis events (Schmit et al., 2018), and decrease in risky drinking behaviors for individuals receiving IC trauma care (Veach et al., 2018). The self-stigma of mental illness and of seeking help had an inverse relationship with mental health literacy among patients who received treatment in an IC setting (Crowe et al., 2017). These results are represented in Appendix B.

Meta-Analyses and Systematic Reviews
     Three articles in this review were meta-analyses or systematic reviews. Specifically, two articles were meta-analyses and one was a systematic review. Participants within these studies included adults with substance use disorders, mental health professionals receiving training to practice within IC, and individuals receiving mental health care in traditional primary care settings. All three articles described benefits of IC. Additionally, the authors differed on the number of studies and participants included in their analyses. Fields et al. (2023) completed a review of 18 articles that studied training interventions for mental health professionals to work on IC teams and concluded that training in IC promotes aspects of interprofessional collaboration, professional identity development, and self-efficacy. Balkin et al. (2019) concluded no statistical significance between IC treatment and TAU to decrease frequency of substance use. Balkin et al. also remarked that their study, including 1,545 participants, did not reach statistical power and results should be considered preliminary. Lenz et al. (2018) reported a decrease in mental health symptoms with a greater effect when a larger treatment team and number of behavioral health sessions are increased, compared to TAU. Lenz and colleagues generated their results from 14,764 participants. Lastly, Fields et al. (2023) and Lenz et al. (2018) both used Heath et al.’s (2013) model of IC for conceptualization. For all three of these studies, additional research is needed to understand IC at the client or consumer level, as well as how different variables affect the treatment process. These results are represented in Appendix C.

Discussion 

Implications for Counseling Practice
     The results of this scoping review have implications that may inform clinical practice for counselors and CITs. Most results suggested clinical benefits for individuals receiving counseling services through an IC setting. Clients or consumers that received IC treatment reported a reduction of mental health symptoms (Lenz et al., 2018; Ulupinar et al., 2021), mental health stigma (Crowe et al., 2018), and crisis events (Schmit et al., 2018). As almost half of individuals with poor mental health receive treatment in primary care settings (Petterson et al., 2014), integrating a counselor into a traditional primary care setting (e.g., hospital, community health care clinic) provides an additional treatment team member with specialized training to treat mental health concerns. Because of the potentially fast nature of IC settings, interested counselors are encouraged to review SAMHSA applications of SBIRT to facilitate brief meetings until more long-term services are provided. Furthermore, counselors may consider reviewing resources on evidence-based approaches, such as Ultra-Brief Cognitive Behavioral Interventions: A New Practice Model for Mental Health and Integrated Care (Sperry and Binensztok, 2019), and understanding common medical terminology, such as A Therapist’s Guide to Understanding Common Medical Conditions (Kolbasovsky, 2008).

Articles that were classified as conceptual also suggested that IC treatment has the potential to enhance service delivery for clients from diverse populations, such as LGBTQ+ and medically underserved communities (Kohn-Wood & Hooper, 2014; Moe et al., 2018). The primary rationale described by scholars is that an IC approach advocates for diverse populations to reduce social determinants of health, such as proximity barriers, communications barriers, and availability of culturally appropriate interventions. Counselors interested in working in an IC setting are strongly encouraged to review the MSJCC (Ratts et al., 2016) and be prepared to serve as an advocate for their client as they navigate the health care system. The Hays (1996) ADDRESSING model also provides counselors a conceptualization model for understanding power and privileges associated with cultural differences. Information drawn from an understanding of power and privileges may further assist the interdisciplinary team with delivering culturally appropriate care. However, Balkin et al. (2019) concluded that IC may not result in a decrease in frequency of substance misuse. As IC may not be the most ideal approach depending on the client’s presenting concern and therapeutic goals, counselors are ethically bound to continue ongoing assessments to collaborate with their client to determine the most appropriate treatment setting.

Implications for Counselor Education
     In addition to counseling practice, the results of our scoping review provide implications for counselor education and ongoing counselor development. First, counselors or CITs that have received training in IC have commonly reported an increase in their professional identity development, as practicing in IC settings creates an opportunity for counselors and CITs to differentiate counseling responsibilities from related health care professionals (Brubaker & La Guardia, 2020; Johnson et al., 2015). Counselor educators and supervisors are encouraged to consider how they can create opportunities to challenge their students or supervisees to understand their role in the health care landscape. For example, Johnson and Freeman (2014) described an interdisciplinary health care delivery course to train counselors alongside students from other disciplines (e.g., nursing, physical therapy), and counselor educators may consider how they can form partnerships across departments to provide these opportunities. Counselor or CIT participants also expressed an enhanced self-efficacy for clinical practice (Brubaker & La Guardia, 2020; Lenz & Watson, 2023). As trainings and field experience for IC practice typically involve experiential components, counselors and CITs are provided additional opportunities to practice their previous clinical trainings in IC settings. Farrell et al. (2009) provided an example of how counselor educators can use standardized patients (i.e., paid actors simulating a presenting concern) to role-play a client in a primary setting. In such situations, the CIT can practice a variety of brief assessments (e.g., substance abuse, suicide, depression screenings) and interventions (e.g., motivational interviewing techniques, such as building ambivalence) in an IC setting.

With the counseling profession’s emphasis on aspects of valuing cultural differences and social justice, counselor educators and supervisors may consider how they can train counselors and CITs to reduce social determinants of health through integrated and collaborative practices that promote affirmative and proximal care. Counselors or CITs that received training to work in IC settings often reported higher understanding of multicultural counseling (Agaskar et al., 2021; Lenz et al., 2018). Thus, counselor educators and supervisors can provide their counselors and CITs with challenges to incorporate aspects of the MSJCC (Ratts et al., 2016) when delivering interdisciplinary care. All trainings in our review were administered across multiple modalities (e.g., face-to-face, hybrid, virtual, asynchronous), which gives counselor educators flexibility in how they train counselors or CITs. The variety in training administration is a promising result, as the COVID-19 pandemic highlighted the need for flexible training options for counselors and CITs. In addition, counselors and CITs in rural communities often have infrequent access to training as compared to their non-rural colleagues, and thus flexibility may enhance the accessibility of IC training (Alvarez et al., 2014). Lastly, counselors and CITs being trained in IC modalities do not need to work in IC settings to use interprofessional skills developed through trainings. Heath et al. (2013) remarked that IC is not always a feasible option, but helping professionals can still apply collaborative approaches to enhance their client’s holistic outcomes. In other words, counselors or CITs may apply IC principles of preventative health care and interdisciplinary treatment plans by collaborating with other health care professionals at a distance. Glueck (2015) corroborated this notion and described a theme that counselors who have previously worked in IC settings believe they are able to provide more holistic care because they are better equipped to collaborate with health care professionals from multiple disciplines. However, these counselors also reported that they would have been more prepared to work in IC if they received training at some point in their career.

Limitations and Recommendations for Future Research
     The methodology of a scoping review has noted limitations. Because of the nature of a scoping review, the data extraction process and results section are broad (Munn et al., 2018). Articles were not systematically evaluated to assess study quality, and the reader is encouraged to review a specific study before interpreting the results. In addition to study quality, scoping reviews include articles from a variety of article classifications, so the results and implications should be considered exploratory. Thus, we caution how readers draw conclusions from results presented in the included articles. Second, the search terms and inclusion criteria may have resulted in limitations. This search focused on IC; therefore, concepts such as interprofessional collaboration and interprofessional education may have been excluded. These concepts are discussed in the Heath et al. (2013) model, but they do not directly result in IC practice. Counseling and counselor education were also search terms, which may have excluded articles written by counseling scholars in journals outside of counseling and counselor education journals. Third, this review resulted in four studies that empirically investigated IC at the client level. With limited data at the client level, there are funding and advocacy sustainability concerns for IC within counseling and counselor education. Lastly, nine studies specifically provided implications for marginalized populations and multicultural competency development through an IC lens. Although Kohn-Wood and Hooper (2014) and Vogel et al. (2014) concluded that IC is a modality that advocates for the treatment of marginalized populations that have traditionally received services at unequal rates to their White, cisgender counterparts, this topic has limited representation in counseling IC literature. As discussed by Fields et al. (2023), this review demonstrates the need for understanding how the counseling professional identity rooted in social justice and advocacy may contribute to the advancement of IC services.

In light of our limitations, this review resulted in recommendations for future research directions. Conceptual articles included in this review synthesized literature on the importance of CITs and counselors understanding applications of IC, as well as potential treatment approaches to treat a variety of marginalized communities and clinical practices. Our research team recommends that counseling scholars reviewing the included conceptual articles consider how they can use the implications and future research directions to inform future research studies. These articles can also serve as support for counseling scholars who are applying for internal and external funding. Furthermore, the empirical studies, systematic reviews, and meta-analyses included in our review present data that can inform future research. For example, Balkin et al. (2019) and Veach et al. (2018) concluded contrasting results about IC in reducing substance abuse behaviors. Future research studies can continue researching substance misuse within IC settings to better understand evidence-based approaches to treat these populations. Twenty-one articles included recommendations for continued research at the client or consumer level, specifically for clients from marginalized communities. Counseling scholars are encouraged to stay up to date with program evaluation scholarship and implement a variety of methodical procedures to document the impact of IC on clients. Lastly, counseling scholars must advocate for continued IC literature publication within counseling and counselor education journals.

Conclusion

Our scoping review identified IC literature within counseling journals. Specifically, this review followed PRISMA-ScR protocols (Tricco et al., 2018) and identified 27 articles across 10 unique counseling journals. Most articles were within national flagship journals (such as those of ACA and AMHCA) and publication years ranged from 2004–2023. The articles in this review were organized according to their classification, and were described as either conceptual, empirical, or meta-analyses and systematic reviews. Implications for CITs, counselors, and clients were represented across each classification. Overall, IC implications from each article were positive for training and practice perceptions for CITs and counselors, as well as clinical outcomes for clients. Moving forward, authors unanimously encouraged counselor educators and counseling scholars to continue studying IC. Future scholarship would benefit from a deeper understanding of client-level implications, with an emphasis on how IC can benefit marginalized communities.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

 

References

Note. Studies with an asterisk (*) are included in the scoping review.

*Agaskar, V. R., Lin, Y.-W. D., & Wambu, G. W. (2021). Outcomes of “integrated behavioral health” training: A pilot study. International Journal for the Advancement of Counselling, 43, 386–405.
https://doi.org/10.1007/s10447-021-09435-z

*Aitken, J. B., & Curtis, R. (2004). Integrated health care: Improving client care while providing opportunities for mental health counselors. Journal of Mental Health Counseling, 26(4), 321–331.
https://doi.org/10.17744/mehc.26.4.tp35axhd0q07r3jk

*Alvarez, K., Marroquin, Y., Sandoval, L., & Carlson, C. (2014). Integrated health care best practices and culturally and linguistically competent care: Practitioner perspectives. Journal of Mental Health Counseling, 36(2), 99–114. https://doi.org/10.17744/mehc.36.2.480168pxn63g8vkg

*Balkin, R. S., Lenz, A. S., Dell’Aquila, J., Gregory, H. M., Rines, M. N., & Swinford, K. E. (2019). Meta-analysis of integrated primary and behavioral health care interventions for treating substance use among adults. Journal of Addictions & Offender Counseling, 40(2), 84–95. https://doi.org/10.1002/jaoc.12067

Basu, S., Landon, B. E., Williams, J. W., Jr., Bitton, A., Song, Z., & Phillips, R. S. (2017). Behavioral health integration into primary care: A microsimulation of financial implications for practices. Journal of General Internal Medicine, 32(12), 1330–1341. https://doi.org/10.1007/s11606-017-4177-9

*Brubaker, M. D., & La Guardia, A. C. (2020). Mixed-design training outcomes for fellows serving at-risk youth within integrated care settings. Journal of Counseling & Development, 98(4), 446–457.
https://doi.org/10.1002/jcad.12346

Council for Accreditation of Counseling and Related Educational Programs. (2015). 2016 CACREP standards. http://www.cacrep.org/wp-content/uploads/2018/05/2016-Standards-with-Glossary-5.3.2018.pdf

Council for Accreditation of Counseling and Related Educational Programs. (2022). 2024 CACREP standards, draft three. https://www.cacrep.org/wp-content/uploads/2022/04/Draft-3-2024-CACREP-Standards.pdf

*Crowe, A., Mullen, P. R., & Littlewood, K. (2018). Self-stigma, mental health literacy, and health outcomes in integrated care. Journal of Counseling & Development, 96(3), 267–277. https://doi.org/10.1002/jcad.12201

Farrell, M. H., Kuruvilla, P., Eskra, K. L., Christopher, S. A., & Brienza, R. S. (2009). A method to quantify and compare clinicians’ assessments of patient understanding during counseling of standardized patients. Patient Education and Counseling, 77(1), 128–135. https://doi.org/10.1016/j.pec.2009.03.013

​​Fields, A. M., Linich, K., Thompson, C. M., Saunders, M., Gonzales, S. K., & Limberg, D. (2023). A systematic review of training strategies to prepare counselors for integrated primary and behavioral healthcare. Counseling Outcome Research and Evaluation, 14(1), 1–14. https://doi.org/10.1080/21501378.2022.2069555

Gerrity, M. (2016). Evolving models of behavioral health integration: Evidence update 2010–2015. Milbank Memorial Fund. https://www.milbank.org/wp-content/uploads/2016/05/Evolving-Models-of-BHI.pdf

Giese, A. A., & Waugh, M. (2017). Conceptual framework for integrated care: Multiple models to achieve integrated aims. In R. E. Feinstein, J. V. Connelly, & M. S. Feinstein (Eds.), Integrating behavioral health and primary care (pp. 3–16). Oxford University Press.

*Glueck, B. P. (2015). Roles, attitudes, and training needs of behavioral health clinicians in integrated primary care. Journal of Mental Health Counseling, 37(2), 175–188. https://doi.org/10.17744/mehc.37.2.p84818638n07447r

Hays, P. A. (1996). Addressing the complexities of culture and gender in counseling. Journal of Counseling & Development, 74(4), 332–338. https://doi.org/10.1002/j.1556-6676.1996.tb01876.x

Health Resources and Services Administration. (2022). Health professions training programs. https://data.hrsa.gov/topics/health-workforce/training-programs

Heath, B., Wise-Romero, P., & Reynolds, K. A. (2013). Standard framework for levels of integrated healthcare. SAMHSA-HRSA Center for Integrated Health Solutions. https://www.thenationalcouncil.org/wp-content/uploads/2020/01/CIHS_Framework_Final_charts.pdf?daf=375ateTbd56

*Jacobson, T., & Hatchett, G. (2014). Counseling chemically dependent chronic pain patients in an integrated care setting. Journal of Addictions & Offender Counseling, 35(1), 57–61.
https://doi.org/10.1002/j.2161-1874.2014.00024.x

*Johnson, K. F., Blake, J., & Ramsey, H. E. (2021). Professional counselors’ experiences on interprofessional teams in hospital settings. Journal of Counseling & Development, 99(4), 406–417. https://doi.org/10.1002/jcad.12393

*Johnson, K. F., & Freeman, K. L. (2014). Integrating interprofessional education and collaboration competencies (IPEC) into mental health counselor education. Journal of Mental Health Counseling, 36(4), 328–344.
https://doi.org/10.17744/mehc.36.4.g47567602327j510

*Johnson, K. F., Haney, T., & Rutledge, C. (2015). Educating counselors to practice interprofessionally through creative classroom experiences. Journal of Creativity in Mental Health, 10(4), 488–506.
https://doi.org/10.1080/15401383.2015.1044683

*Johnson, K. F., & Mahan, L. B. (2020). Interprofessional collaboration and telehealth: Useful strategies for family counselors in rural and underserved areas. The Family Journal, 28(3), 215–224.
https://doi.org/10.1177/1066480720934378

*Kohn-Wood, L., & Hooper, L. (2014). Cultural competency, culturally tailored care, and the primary care setting: Possible solutions to reduce racial/ethnic disparities in mental health care. Journal of Mental Health Counseling, 36(2), 173–188. https://doi.org/10.17744/mehc.36.2.d73h217l81tg6uv3

Kolbasovsky, A. (2008). A therapist’s guide to understanding common medical conditions: Addressing a client’s mental and physical health. W. W. Norton.

*Lenz, A. S., Dell’Aquila, J., & Balkin, R. S. (2018). Effectiveness of integrated primary and behavioral healthcare. Journal of Mental Health Counseling40(3), 249–265. https://doi.org/10.17744/mehc.40.3.06

*Lenz, A. S., & Watson, J. C. (2023). A mixed methods evaluation of an integrated primary and behavioral health training program for counseling students. Counseling Outcome Research and Evaluation, 14(1), 28–42.
https://doi.org/10.1080/21501378.2022.2063713

*Lloyd-Hazlett, J., Knight, C., Ogbeide, S., Trepal, H., & Blessing, N. (2020). Strengthening the behavioral health workforce: Spotlight on PITCH. The Professional Counselor, 10(3), 306–317.
https://doi.org/10.15241/jlh.10.3.306

McCall, M. H., Wester, K. L., Bray, J. W., Hanchate, A. D., Veach, L. J., Smart, B. D., & Wachter Morris, C. (2022). SBIRT administered by mental health counselors for hospitalized adults with substance misuse or disordered use: Evaluating hospital utilization and costs. Journal of Substance Abuse Treatment, 132, 108510. https://doi.org/10.1016/j.jsat.2021.108510

*Moe, J., Johnson, K., Park, K., & Finnerty, P. (2018). Integrated behavioral health and counseling gender and sexual minority populations. Journal of LGBT Issues in Counseling, 12(4), 215–229.
https://doi.org/10.1080/15538605.2018.1526156

Munn, Z., Peters, M. D. J., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 18(1), 1–7. https://doi.org/10.1186/s12874-018-0611-x

Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stat. 119 (2010).
https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf

Petterson, S., Miller, B. F., Payne-Murphy, J. C., & Phillips, R. L., Jr. (2014). Mental health treatment in the primary care setting: Patterns and pathways. Families, Systems, & Health, 32(2), 157–166.
https://doi.org/10.1037/fsh0000036

Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48. https://doi.org/10.1002/jmcd.12035

*Regal, R. A., Wheeler, N. J., Daire, A. P., & Spears, N. (2020). Childhood sexual abuse survivors undergoing cancer treatment: A case for trauma-informed integrated care. Journal of Mental Health Counseling, 42(1), 15–31. https://doi.org/10.17744/mehc.42.1.02

*Schmit, M. K., Watson, J. C., & Fernandez, M. A. (2018). Examining the effectiveness of integrated behavioral and primary health care treatment. Journal of Counseling & Development, 96(1), 3–14.
https://doi.org/10.1002/jcad.12173

*Sheesley, A. P. (2016). Counselors within the chronic care model: Supporting weight management. Journal of Counseling & Development, 94(2), 234–245. https://doi.org/10.1002/jcad.12079

Sperry, L., & Binensztok, V. (2019). Ultra-brief cognitive behavioral interventions: A new practice model for mental health and integrated care. Routledge.

Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf

The White House. (2022, March 1). Fact sheet: President Biden to announce strategy to address our national mental health crisis, as part of unity agenda in his first State of the Union. [Press release]. https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-president-biden-to-announce-strategy-to-address-our-national-mental-health-crisis-as-part-of-unity-agenda-in-his-first-state-of-the-union

Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., . . . Straus, S. E. (2018). PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Annals of Internal Medicine, 169(7), 467–473. https://doi.org/10.7326/M18-0850

*Tucker, C., Sloan, S. K., Vance, M., & Brownson, C. (2008). Integrated care in college health: A case study. Journal of College Counseling, 11(2), 173–183. https://doi.org/10.1002/j.2161-1882.2008.tb00033.x

*Ulupinar, D., Zalaquett, C., Kim, S. R., & Kulikowich, J. M. (2021). Performance of mental health counselors in integrated primary and behavioral health care. Journal of Counseling & Development, 99(1), 37–46.
https://doi.org/10.1002/jcad.12352

*Veach, L. J., Moro, R. R., Miller, P., Reboussin, B. A., Ivers, N. N., Rogers, J. L., & O’Brien, M. C. (2018). Alcohol counseling in hospital trauma: Examining two brief interventions. Journal of Counseling & Development, 96(3), 243–253. https://doi.org/10.1002/jcad.12199

*Vereen, L. G., Yates, C., Hudock, D., Hill, N. R., Jemmett, M., O’Donnell, J., & Knudson, S. (2018). The phenomena of collaborative practice: The impact of interprofessional education. International Journal for the Advancement of Counselling, 40(4), 427–442. https://doi.org/10.1007/s10447-018-9335-1

*Vogel, M., Malcore, S., Illes, R., & Kirkpatrick, H. (2014). Integrated primary care: Why you should care and how to get started. Journal of Mental Health Counseling, 36(2), 130–144.
https://doi.org/10.17744/mehc.36.2.5312041n10767k51

*Wood, A. W., Zeligman, M., Collins, B., Foulk, M., & Gonzalez-Voller, J. (2020). Health orientation and fear of cancer: Implications for counseling and integrated care. Journal of Mental Health Counseling, 42(3), 265–279. https://doi.org/10.17744/mehc.42.3.06

 

Appendix A

Conceptual Articles

Author(s) Population(s) of Interest Research Gap Identified Implications and Future Directions
Aitken & Curtis, 2004 Counselor educators
and counselors
Lack of IC literature in counselor education journals Increased training for counselors to work competently in IC. Increased advocacy efforts to be on insurance panels. Build relationships with other health care professionals. More literature is needed in counselor education journals.
Jacobson & Hatchett, 2014 Clients who are chemically dependent with chronic pain Lack of literature for clients who are chemically dependent with chronic pain Clients that have co-occurring chemical dependence and chronic pain have reported benefits when their symptoms are treated by mental and physical health providers. Additional research is needed to understand treatment strategy effectiveness.
Johnson & Freeman, 2014 Health care undergraduate and graduate students (including CITs)
learning IC strategies
Lack of literature documenting IC training across multiple disciplines, specifically including CITs Provides a framework for IC training across multiple disciplines in accordance with SAMHSA IC competency standards. Additional research is needed to understand the effectiveness for each discipline and as a whole.
Johnson & Mahan, 2020 Family counselors
in rural and
underserved areas
Family counselors leading connection between rural families and other providers
of health care services
Emphasis on interprofessional collaboration (IPC) and use of telehealth options where family counselors use systemic training to advocate for rural, marginalized families, as well as network and connect families to health care providers when family members have unmet medical health needs or need specialized mental health care treatment. Additional research is needed to understand this phenomenon.
Kohn-Wood & Hooper, 2014 Mental health professionals working
in primary care settings
How culturally tailoring evidence-based treatment models can reduce mental health disparities Cultural tailoring of treatments should be a primary factor that is evaluated in future research studies. Future researchers should consult existing literature on culturally tailoring treatment to increase engagement and improve outcomes for diverse groups.
Lloyd-Hazlett et al., 2020 CITs Need for a replicable model
to train CITs in IC
The Program for the Integrated Training of Counselors in Behavioral Health (PITCH) model creates community partnerships, introduces CITs to applications of IC, and awards CITs a graduate certificate. Additional research is needed to demonstrate sustainability.
Moe et al., 2018 LGBTQ+ clients Lack of LGBTQ+ literature pertaining to IC CITs, counselors, and other health care professionals working with LGBTQ clients may benefit from additional training and supervision in collaborative care and IC. Additional research is needed to understand the impact IC has with the LGBTQ+ population.
Regal et al., 2020 Clients with cancer who are survivors of childhood sexual abuse Lack of trauma-informed
care literature pertaining
to IC, specifically for individuals with adverse childhood experiences (ACEs)
IC offers opportunities for appropriate assessments to identify ACEs for holistic care, as represented in the case study. Additional research is needed to understand universal screening for ACEs and the integration of trauma-informed practices within traditional primary care settings.
Sheesley, 2016 Counselor educators, counselors, and primary care settings Elaborate on the role of mental health counselors within the Chronic Care Model (CCM) Counselors influencing the future of obesity treatment within the CCM. Additional research is needed to understand evidence-based practices for counselors within the CCM for the treatment of obesity.
Tucker et al., 2008 An international student’s experience receiving IC on a college campus The effect of an IC program and mindfulness-based cognitive therapy (MCBT) approach As reported by the multidisciplinary team, clients using medication and individual and group therapy improved from the first time they had met. The authors emphasized the use of MCBT in treatment. Additional research is needed for IC on college campuses.
Vogel et al., 2014 Counselors considering IPC Access issues, adherence, and the effectiveness of IPC with particular attention to culturally diverse groups Increased training in evidence-based culturally tailored practices. Increased education for counselors regarding IPC to help determine if primary care is a good fit. Additional research is needed on various aspects of successful IPC execution.

 

Appendix B

Empirical Articles

Author(s) Methodology N and
Participant
Profile
Research of Interest Results
Agaskar
et al., 2021
Mixed methods; quantitative: single-group design; qualitative: thematic analysis 12 CITs The effect of an IPC and evidence-based practices curriculum to enhance students’ ability to work with at-risk youth in IC settings CITs reported an increase in multicultural competence and ability to work on IC teams, utilize evidence-based practices, and implement suicide interventions.
Alvarez
et al., 2014
Qualitative; exploratory
cross-case synthesis
8 service providers in an IC setting The experiences of IC service providers working with culturally and linguistically diverse populations Three themes emerged: (a) patient-centered care benefits underserved populations, (b) desirability of a multidisciplinary team, and
(c) importance of the organization to change with circumstances.
Brubaker & La Guardia, 2020 Quantitative;
single case and quasi-experimental
11 CITs The effect of an IC training intervention, Serving At-Risk Youth Fellowship Experience for Counselors (SAFE-C) CITs reported an increase in understanding professional identity, self-efficacy, and interprofessional socialization.
Crowe
et al., 2017
Quantitative;
Cross-sectional survey design
102 clients from an IC medical facility To examine the relationship between mental health self-stigmas, mental health literacy, and health care outcomes Self-stigma of mental illness and self-stigma of seeking help had an inverse relationship with mental health literacy.
Glueck 2015 Qualitative; phenomenological 10 mental health professionals working in IC settings Roles and attitudes of mental health professionals working in IC and perceived training needs Mental health professionals reported that they were involved in brief interventions and assessments, administrative work, and consultation and that additional graduate training is needed in classroom and field experiences.
Johnson
et al., 2015
Mixed methods; qualitative: the pre- and post-survey design; qualitative: thematic analysis 22 CITs, as well as dental hygiene, nursing, and
physical therapy students
CITs’ attitudes toward interprofessional learning and collaboration following an interdisciplinary course on IPC Perceptions about learning together and collaboration improved, negative professional identity scores decreased, and higher reports of positive professional identity.
Johnson
et al., 2021
Qualitative; phenomenology 11 counselors in hospital setting Experiences of counselors working on interprofessional teams (IPTs) in a hospital setting Four themes emerged:
(a) counselors rely on common factors and foundational principles; (b) counselors must have interprofessional supervision; (c) counselors must remember their scope of practice; and (d) counselors must adhere to ethical codes and advocacy standards.
Lenz & Watson, 2023 Mixed-methods; quantitative: non-experimental pre- and post-test; qualitative: thematic analysis 45 CITs The impact an IC training program has on CITs’ self-efficacy, interprofessional socialization, and multicultural competence, as well as barriers to student growth Increase in self-efficacy, interprofessional socialization, and aspects of multicultural competence. Most reported barriers were IC awareness and organizational constraints.
Schmit
et al., 2018
Quantitative;
quasi-experimental
196 clients; 98 received IC and 98 received treatment as usual (TAU) The effect of IC for individuals with severe mental illness compared
to TAU
Group that received the IC intervention demonstrated an improvement in overall functioning, including a
decrease in crisis events.
Ulupinar et al., 2021 Quantitative;
quasi-experimental
1,747 clients and 10 counselors To examine the therapeutic outcomes and client dropout rates of adults experiencing mental disorders in an IC center The addition of counselors resulted in a decrease in client symptom reports.
Veach
et al., 2018
Quantitative; pre- and post-test survey 333 clients in a trauma-based IC center A brief IC counseling intervention for risky alcohol behavior The IC counseling intervention resulted in reduced risky alcohol behaviors.
Vereen
et al., 2018
Qualitative; phenomenological inquiry 13 graduate students; five CITs  and eight speech– language pathologists The effect of interprofessional education (IPE) on the development of collaborative practice for both CITs and speech– language pathologists-in-training Five themes emerged:

(a) benefits of IPE,
(b) expectations of collaborative practice, (c) benefits of experienced IC providers,
(d) challenges of IC practice, and
(e) optimization of IC practice.

Wood
et al., 2020
Quantitative;
cross-sectional survey design
155 undergraduate students studying psychology and aspects of counseling How factors related to prevention and wellness relate to topics that counselors are adept at addressing, such as optimism, social support, and resilience Results indicated that health anxiety was positively correlated with fear of cancer, but that psychosocial variables either had no relationship or were not significant moderators between health anxiety and fear of cancer.

 

Appendix C

Meta-Analyses and Systematic Reviews

Author(s) Article Classification Population of Interest Number
of Included Studies and Participants
Results and Implications
Balkin
et al., 2019
Meta-analysis Adults with substance use disorders 8 studies with 1,545 participants;
722 received IC and 823
received alternative
Effects of IC were small with this sample (i.e., small effect in decrease in substance use).
Authors recommended additional research to understand substance use disorders within an IC context and variables beyond use of substances.
Fields
et al., 2023
Systematic review Mental health professionals and mental health professionals-in-training receiving education on IC 18 studies Four themes emerged:
(a) HRSA-funded studies,
(b) trainee skill development, (c) enhancement of
self-efficacy, and
(d) increased understanding of interprofessional collaboration. Authors recommended more studies focusing on client-level data and more multicultural competencies.
Lenz
et al., 2018
Meta-analysis Individuals receiving mental health care in traditional primary care settings 36 studies with 14,764 participants Effects of IC, as compared to alternative treatments, resulted in a decrease in mental health symptoms. A greater effect is shown with a larger treatment team and number of behavioral health sessions.

 

Alexander M. Fields, PhD, is an assistant professor at the University of Nebraska at Omaha. Cara M. Thompson, PhD, is an assistant professor at the University of North Carolina at Pembroke. Kara M. Schneider, MS, is a doctoral candidate at the University of South Carolina. Lucas M. Perez, MA, is a doctoral candidate at the University of South Carolina. Kaitlyn Reaves, BS, is a doctoral student at Adler University. Kathryn Linich, PhD, is a clinical assistant professor at Duquesne University. Dodie Limberg, PhD, is an associate professor at the University of South Carolina. Correspondence may be addressed to Alexander M. Fields, University of Nebraska at Omaha, College of Education, Health, and Human Services, Department of Counseling, Omaha, NE 68182, alexanderfields@unomaha.edu.

Whiteness Scholarship in the Counseling Profession: A 35-Year Content Analysis

Hannah B. Bayne, Danica G. Hays, Luke Harness, Brianna Kane

 

We conducted a content analysis of counseling scholarship related to Whiteness for articles published in national peer-reviewed counseling journals within the 35-year time frame (1984–2019) following the publication of Janet Helms’s seminal work on White racial identity. We identified articles within eight counseling journals for a final sample of 63 articles—eight qualitative (12.7%), 38 quantitative (60.3%), and 17 theoretical (27.0%). Our findings outline publication characteristics and trends and present themes for key findings in this area of scholarship. They reveal patterns such as type of research methodology, sampling, correlations between White racial identity and other constructs, and limitations of White racial identity assessment. Based on this overview of extant research on Whiteness, our recommendations include future research that focuses on behavioral and clinical manifestations, anti-racism training within counselor education, and developing a better overall understanding of how White attitudes and behaviors function for self-protection.

Keywords: Whiteness, White racial identity, counseling scholarship, counseling journals, content analysis

 

Counselors are ethically guided to understand and address the roles that race, privilege, and oppression play in impacting both themselves and their clients (American Counseling Association [ACA], 2014). Most practitioners identify as White despite the population diversity in the United States (U.S. Census Bureau, 2020), which holds implications for understanding how Whiteness impacts culturally competent counselor training and practice (Helms, 1984, 1995, 2017). It is important, then, to understand the role of racial identity within counseling, particularly in terms of how Whiteness can be deconstructed and examined as a constant force impacting power dynamics and client progress (Helms, 1990, 2017; Malott et al., 2015). Whiteness models (i.e., Helms, 1984) describe how White people make meaning of their own and others’ racial identity as a result of personal and social experiences with race (Helms, 1984, 2017). The Helms model, along with other constructs, such as color-blindness (Frankenberg, 1993), White racial consciousness (Claney & Parker, 1989), and White fragility (DiAngelo, 2018), implicates the harmful impacts of Whiteness and invites critical reflection of how these constructs impact the counseling process.

Though much has been theorized regarding Whiteness and its impact within the helping professions, the contributions of Whiteness scholarship within professional counseling journals are unclear. An understanding of the specific professional applications and explorations of Whiteness within counseling can help identify best practices in counselor education, research, and practice to counter the harmful impacts of Whiteness and encourage growth toward anti-racist attitudes and behaviors.

White Racial Identity and Related Constructs
     The Helms (1984) model of White racial identity (WRI) presents Whiteness as a developmental process centering on racial consciousness (i.e., the awareness of one’s own race), as well as awareness of attitudes and behaviors toward other racial groups (Helms, 1984, 1990, 1995, 2017). According to Helms, White people have the privilege to restrict themselves to environments and relationships that are homogenous and White-normative, thus limiting their progression through the stages (DiAngelo, 2018; Helms, 1984). The initial model (Helms, 1984) contained five stages (i.e., Contact, Disintegration, Reintegration, Pseudo-Independence, and Autonomy), each with a positive or negative response that could facilitate progression toward a more advanced stage, regression to earlier stages of the model, or stagnation at the current stage of development. Helms (1990) later added a sixth status, Immersion/Emersion, to the model as an intermediary between Pseudo-Independence and Autonomy. These final three stages of the model (i.e., Pseudo-Independence, Immersion/Emersion, Autonomy) involve increasing levels of racial acceptance and intellectual and emotional comfort with racial issues, which in turn leads to the development of a positive and anti-racist WRI (Helms, 1990, 1995).WRI requires intentional and sustained attention toward how Whiteness impacts the self and others, with progression through the stages leading to beneficial intra and interpersonal outcomes (Helms, 1990, 1995, 2017).

Since Helms (1984), several additional components of Whiteness have been introduced, primarily within psychology, counseling psychology, and sociology scholarship. White racial consciousness is distinct from the WRI model in its focus on attitudes toward racial out-groups, rather than using the White in-group as a reference point (Choney & Behrens, 1996; Claney & Parker, 1989). Race essentialism refers to the degree to which a person believes that race reflects biological differences that influence personal characteristics (Tawa, 2017). Symbolic/modern racism refers to overt attitudes of White people related to their perceived superiority (Henry & Sears, 2002; McConahay, 1986). A fourth Whiteness component, color-blind racial ideology, enables color-evasion (i.e., “I don’t see color”) and power-evasion roles (i.e., “everyone has an equal chance to succeed”), which allow White people to deny the impact of race and therefore evade a sense of responsibility for oppression (Frankenberg, 1993; Neville et al., 2013). White privilege refers to the systemic and unearned advantages provided to White people over people of color (McIntosh, 1988). There are also psychosocial costs accrued to White people as a result of racism that include (a) affective (e.g., anxiety and fear, anger, sadness, guilt and shame); (b) cognitive (i.e., distorted views of self, others, and reality in general related to race); and (c) behavioral (i.e., avoidance of cross-racial situations or loss of relationships with White people) impacts (Spanierman & Heppner, 2004). White fragility (DiAngelo, 2018) reflects defensive strategies White people use to re-establish cognitive and affective equilibrium regarding their own Whiteness and impact on others.

Whiteness concepts are thus varied, with different vantage points of how White people might engage in the consideration of power, privilege, and racism, and what potential implications these constructs might have on their development. These constructs also seem largely rooted in psychology research, and it is therefore unclear the extent to which counselor educators and researchers have examined and applied these constructs to training and practice. Such an analysis can assist in situating Whiteness within the specific contexts and professional roles of counseling and can identify areas in need of further study.

The Present Study
     Because of the varied components of Whiteness, as well as its potential impact on counselor development and counseling process and outcome (Helms, 1995, 2017), there is a need to examine how these constructs have been examined and applied within counseling research. We sought to identify how and to what degree Whiteness constructs have been explored or developed within the counseling profession since the publication of the Helms (1984) model. We hope to summarize empirical and theoretical constructs related to Whiteness in national peer-reviewed counseling journals to more clearly consider implications for training and practice. Such analysis can highlight the saliency of WRI, demonstrating the need for continued focus on the influences and impacts of Whiteness within counseling. The following research questions were addressed: 1) What types of articles, topics, and major findings are published on Whiteness?; 2) What are the methodological features of articles published on Whiteness?; and 3) What are themes from key findings across these publications?

Method

We employed content analysis to identify publication patterns of national peer-reviewed counseling journals regarding counseling research on Whiteness in order to understand the scope and depth of this scholarship as it applies to fostering counselor training and practice. Content analysis is the systematic review of text in order to produce and summarize numerical data and identify patterns across data sources regarding phenomena (Neuendorf, 2017). In addition, content analysis has been used to summarize and identify patterns for specific topics, including multicultural counseling (e.g., Singh & Shelton, 2011).

Data Sources and Procedure
     The sampling units for this study were journal articles on Whiteness topics published in national peer-reviewed journals (N = 24) of the ACA and its divisions, the American School Counselor Association, the American Mental Health Counselors Association, the National Board for Certified Counselors, and Chi Sigma Iota International. We used the following search terms: White supremacy, White racial identity, White privilege, White fragility, White guilt, White shame, White savior, White victimhood, color-blindness, race essentialism, anti-racism, White racism, reverse racism, White resistance, and Whiteness. We selected a 35-year review period (i.e., 1984–2019) to correspond with Helms’s (1984) foundational work on WRI.

We reviewed article abstracts to identify an initial sampling unit pool (N = 185 articles; 29 qualitative [15.6%], 56 quantitative [30.3%], and 100 theoretical [54.1%]). In pairs, we reviewed the initial pool to more closely examine each sampling unit for inclusion in analysis. We excluded 122 articles upon closer inspection (e.g., special issue introductions, personal narratives or profiles, broader focus on social justice issues, ethnic identity, multiculturalism, or primary focus on another racial group). This resulted in a final sample of 63 articles—eight qualitative (12.7%), 38 quantitative (60.3%), and 17 theoretical (27.0%; see Table 1).

Research Team
     Our team consisted of four researchers: two counselor education faculty members and two counselor education doctoral students. We all identify as White. Hannah B. Bayne and Danica G. Hays hold doctorates in counselor education, and Luke Harness and Brianna Kane hold master’s degrees in school counseling and mental health counseling, respectively. We were all trained in qualitative research methods, and Bayne and Hays have conducted numerous qualitative research projects, including previous content analyses. Bayne and Hays trained Harness and Kane on content analysis through establishing coding protocols and coding together until an acceptable inter-rater threshold was met.

 

Table 1

Exclusion and Inclusion of Articles by Journal and Article Type

Journal Excludeda Included Total

Sample

% of

Final

Sample

Quant Qual Theory Quant Qual Theory
Journal of Counseling & Development 5 0 11 16 4 5 24 38.1%
Journal of Multicultural Counseling and
Development
3 3 14 14 3 8 24 38.1%
Counselor Education and Supervision 1 0   1 4 1 2   7 11.1%
The Journal of Humanistic Counseling 1 2 14 1 1 1   3 4.8%
Journal of Mental Health Counseling 0 0   2 1 0 3   2 3.2%
Counseling and Values 0 0   0 1 0 0   1 1.6%
The Family Journal 1 1   5 0 0 2   1 1.6%
Journal of Creativity in Mental Health 0 2   4 0 0 1   1 1.6%
Adultspan Journal 0 0   0 0 0 0   0 0%
The Career Development Quarterly 0 0   0 0 0 0   0 0%
Counseling Outcome Research
and Evaluation
0 2   0 0 0 0   0 0%
Journal for Social Action in Counseling
and Psychology
0 0   3 0 0 0   0 0%
The Journal for Specialists in Group Work 0 1   6 0 0 0   0 0%
Journal of Addictions & Offender
Counseling
0 0   0 0 0 0   0 0%
Journal of Child and Adolescent Counseling 0 0   0 0 0 0   0 0%
Journal of College Counseling 2 0   0 0 0 0   0 0%
Journal of Counselor Leadership
and Advocacy
1 5   6 0 0 0   0 0%
Journal of Employment Counseling 2 0   4 0 0 0   0 0%
Journal of LGBTQ Issues in Counseling 0 1   2 0 0 0   0 0%
Journal of Military and Government
Counseling
0 0   0 0 0 0   0 0%
Measurement and Evaluation in
Counseling and Development
1 0   2 0 0 0   0 0%
Professional School Counseling 0 0   2 0 0 0   0 0%
Rehabilitation Counseling Bulletin 3 1   2 0 0 0   0 0%
The Professional Counselor 0 1   0 0 0 0   0 0%
Professional School Counseling 0 0    2 0 0 0   0 0%

Note. Quant = quantitative research articles; Qual = qualitative research articles; Theory = theoretical articles.
aArticles were excluded from analysis if they did not directly address Whiteness or White racial identity (e.g., special issue introductions, personal narratives or profiles, broader focus on social justice issues, ethnic identity, multiculturalism, or primary focus on another racial group).

 

Coding Frame Development
Dimensions and categories for our coding frame included: journal outlet, publication year, author characteristics (i.e., name, institutional affiliation, ACES region), article type, sample characteristics (e.g., composition, size, gender, race/ethnicity), research components (e.g., research design, data sources or instrumentation, statistical methods, research traditions, trustworthiness strategies), topics discussed (e.g., WRI attitudes, counselor preparation models, intervention use, client outcomes, counseling process), article implications and limitations, and a brief statement of key findings. Over the course of research team meetings, we reviewed and operationalized the coding frame dimensions and categories. We then selected one empirical and one conceptual article to code together in order to refine the coding frame, which resulted in further clarification of some categories. 

Data Analysis
     To establish evidence of replicability (Neuendorf, 2017), we coded eight (12.7%) randomly selected cases proportionate to the sample composition (i.e., two conceptual, four quantitative, two qualitative). We analyzed the accuracy rate of coding using R data analysis software for statistical analysis (LoMartire, 2020). Across 376 possible observations for eight cases, there was an acceptable rate of coding accuracy (0.89). In addition, pairwise Pearson-product correlations among raters indicated that coding misses did not follow a systematic pattern for any variable (r = −.10 to .65), and thus there were no significant variations in coding among research team members. After pilot coding, we met to discuss areas of coding misses to ensure understanding of the final coding frame.

For the main coding phase, we worked in pairs and divided the sample equally for independent and consensus coding. Upon completion of consensus coding of the entire sample, we extracted 29 keywords describing the Whiteness topics discussed in the articles. Bayne and Hays reviewed the 29 independent topics and collapsed the topics into eight larger themes. To identify themes across the key findings, Bayne and Harness reviewed 125 independent statements based on coder summaries of article findings, and through independent and consensus coding collapsed statements to yield three main themes.

Results

Article Characteristics
     We focused on several article characteristics (Research Question 1): article type (conceptual, quantitative, qualitative); number of relevant articles per journal outlet; the relationship between journal outlet and article type; and frequency of Whiteness topics within and across journal outlets. Of the 24 national peer-reviewed counseling journals, eight journals (33.3%) contained publications that met inclusion criteria (i.e., contained keywords for Whiteness from our search criteria and focused specifically on WRI). The number of publications in those journals ranged from 1 to 24 (M = 2.5; Mdn = 7.88; SD = 10.15) and are listed in order of frequency in Table 2). There was not a significant relationship between the journal outlet and article type (i.e., quantitative, qualitative, conceptual) for this topic (r = 0.04, p = .39).

 

Table 2

Articles Addressing Whiteness and Associated Keywords in National Peer-Reviewed Counseling Journals

Journal Articles Addressing Whiteness Percent of Total Sample
Journal of Counseling & Development 24 38.1%
Journal of Multicultural Counseling and Development 24 38.1%
Counselor Education and Supervision  7 11.1%
The Journal of Humanistic Counseling  3 4.8%
Journal of Mental Health Counseling  2 3.2%
Counseling and Values  1 1.6%
The Family Journal  1 1.6%
Journal of Creativity in Mental Health  1 1.6%
Adultspan Journal  0   0%
The Career Development Quarterly  0   0%
Counseling Outcome Research and Evaluation  0   0%
Journal for Social Action in Counseling and Psychology  0   0%
The Journal for Specialists in Group Work  0   0%
Journal of Addictions & Offender Counseling  0   0%
Journal of Child and Adolescent Counseling  0   0%
Journal of College Counseling  0   0%
Journal of Counselor Leadership and Advocacy  0   0%
Journal of Employment Counseling  0   0%
Journal of LGBTQ Issues in Counseling  0   0%
Journal of Military and Government Counseling  0   0%
Measurement and Evaluation in Counseling and
Development
 0   0%
Professional School Counseling  0   0%
Rehabilitation Counseling Bulletin  0   0%
The Professional Counselor  0   0%
Professional School Counseling  0   0%

 

    Additionally, we identified eight themes of topics discussed within counseling research on Whiteness (see Table 3). For qualitative research, the three most frequently addressed topics were theory development, intrapsychic variables, and multicultural counseling competency (MCC). The most frequent topics discussed in theoretical articles were theory development, counselor preparation, Whiteness and WRI expression, cultural identity development, and counseling process.

 

Table 3 

Themes in Topics Discussed Within Whiteness and WRI Articles

Theme Description N

%

Quant

n / %

Qual

n / %

Theory

n / %

Examples
Whiteness and WRI Expression Attitudes and knowledge related to WRI and Whiteness constructs, with some (n = 5) examining pre–posttest changes

 

43

68.3%

32 74.4% 3

7.0%

8

18.6%

WRI attitudes, color-blind racial attitudes, racism and responses, White privilege and responses, and developmental considerations

 

Cultural Identity Development Cultural identities and developmental processes outside of race

 

27

42.9%

21

77.8%

1

3.7%

5

18.5%

Ethnic identity, womanist identity, cultural demographics such as gender and age

 

Counselor Preparation Training implications, with some presenting training intervention findings (n = 6)

 

23

36.5%

17

73.9%

1

4.3%

5

21.8%

Pedagogy, training interventions, and supervision process and outcome

 

Theory Development Development or expansion of theoretical concepts 18

28.6%

5

27.8%

5

27.8%

8

44.4%

White racial consciousness versus WRI, prominent responses to White privilege, psychological dispositions of White racism

 

Multicultural Counseling Competency Measurements of perceived multicultural counseling competency

 

12

19.0%

10

83.3%

2

16.7%

0

0.0%

Perceived competency,
link with WRI
Counseling Process Counseling process and outcome variables

 

11

17.5%

8

72.7%

1

9.1%

2

18.2%

Client perceptions, working alliance, and clinical applications

 

Intrapsychic Variables Affective and cognitive components that influence Whiteness and WRI

 

11

17.5%

8

72.7%

2

18.2%

1

9.1%

Personality variables, cognitive development, ego development

 

Assessment Characteristics Development and/or critique of Whiteness and WRI measurements

 

9

14.3%

8

88.9%

0

0.0%

1

11.1%

Limitations of WRI scales, development of White privilege awareness scales
Totala 154

 

111

72.1%

15

9.7%

30

19.5%

Note. Quant = quantitative research articles; Qual = qualitative research articles; Theory = theoretical articles.
aPercentage total exceeds 100% because of rounding and/or topic overlap between articles.

 

Methodological Features
     To address Research Question 2, we explored the methodological features of articles. These features included sample composition, research design, data sources, and limitations as reported within each empirical article (n = 46).

Sample Composition
     For the 45 studies providing information about the racial/ethnic composition of their samples, White individuals accounted for a mean of 91% of total participants (range = 55%–100%; SD = 14). An average of 14% Black (SD = 6.7), 7.1% Latinx (SD = 4.7), 5.4% Asian (SD = 2.3), and less than 5% each of multiracial, Arab, and Native American respondents were included across the samples. Of studies reporting gender (n = 44), women accounted for an average of 68% of total participants (range = 33–100; SD = 14.7), and men accounted for 31% of total samples (range = 12–67; SD = 14). The age of participants, reported in 71.7% of the empirical studies, ranged from 16 to 81 (M = 29, SD = 8.2).

Of the 61 independent samples across the articles, a majority focused on student populations, with master’s trainees (n = 20, 32.8%), undergraduate students (n = 14, 21.9%), and doctoral trainees (n = 10, 16.4%) representing over 70% of the sample. The remainder of the samples included practitioners (n = 8, 13.1%), unspecified samples (n = 3, 4.9%), university educators (n = 2, 3.3%), educational specialist trainees (n = 2, 3.3%), site supervisors (n = 1, 1.6%), and general population adult samples (n = 1, 1.6%). The target audience of the articles (N = 63) focused primarily on counselor trainees (n = 34, 49.3%) or clients in agency/practice settings (n = 12, 17.4%). Other audiences included practitioners (n = 9, 13%), researchers (n = 3, 4.3%), general population (n = 6, 8.7%), counselor educators (n = 1, 1.4%), and general university personnel (n = 1, 1.4%).

Research Design and Data Sources
     Of the 38 quantitative articles, 10 (26.3%) included an intervention as part of the research design. The majority employed a correlational design (n = 27, 71.1%), with the remainder consisting of four (10.5%) descriptive, four (10.5%) quasi-experimental, one (2.6%) ex post facto/causal comparative, one (2.6%) pre-experimental, and one (2.6%) true experimental design. In recruiting and selecting samples, most researchers used convenience sampling (n = 27, 57.4%), while the rest used purposive (n = 12, 31.6%), simple random (n = 5, 10.6%), stratified (n = 2, 4.3%), and homogenous (n = 1, 2.1%) sampling methods.

Regarding study instrumentation, 37 quantitative studies utilized self-report forced-choice surveys, with one study employing a combination of forced-choice and open-ended question surveys. Across the 38 quantitative studies, 13 of 50 (26%) assessments were used more than once. The most frequently used assessment was the White Racial Identity Attitudes Scale (n = 24; Helms & Carter, 1990). The 50 assessments purported to measure the following targeted variables: race/racial identity/racism (n = 17, 34%); MCC (n = 9, 18%); cultural identity (n = 6, 12%); counseling process and outcome (n = 5, 10%); social desirability (n = 2, 4%); and other variables such as personality, anxiety, and ego development (n = 11, 22%). Finally, data analysis procedures included ANOVA/MANOVA (n = 25, 30.9%), correlation (n = 23, 28.4%), regression (n = 17, 21%), t-tests (n = 7, 8.6%), descriptive (n = 5, 6.2%), exploratory factor analysis (n = 1, 1.2%), confirmatory factor analysis (n = 1, 1.2%), SEM/path analysis (n = 1, 1.2%), and cluster analysis (n = 1, 1.2%).

We identified the research traditions of the eight qualitative studies as follows: phenomenology (n = 3, 37.5%), grounded theory (n = 2, 25%), and naturalistic inquiry (n = 1, 12.5%); two were unspecified (25%). The most common qualitative recruitment method was criterion sampling (n = 5, 62.5%), followed by convenience (n = 3, 37.5%), homogenous (n = 2, 25%), snowball/chain (n = 2, 25%), intensity (n = 2, 25%), and stratified purposeful (n = 1, 12.5%) sampling procedures. (Several studies used multiple recruitment methods, resulting in totals greater than 100%.) There were 12 data sources reported across the eight qualitative studies, falling into the following categories: individual interviews (n = 7, 58.3%), focus group interviews (n = 2, 16.7%), artifacts/documents (n = 2, 16.7%), and observations (n = 1, 8.3%). Trustworthiness strategies included prolonged engagement (n = 7, 13.7%); use of a research team (n = 6, 11.8%); researcher reflexivity, triangulation of data sources, thick description, and simultaneous data collection and analysis (n = 5 each, 9.8%); peer debriefing, audit trail, and member checking (n = 4 each, 7.8%); theory development (n = 3, 5.9%); and one each (2%) of external auditor, memos and/or field notes, and persistent observation.

Limitations Within Sampled Studies
     Of the 46 empirical studies, 44 (95.7%) reported limitations. Limitations included design issues related to sampling/generalizability (n = 38, 82.6%); self-report/social desirability (n = 23, 50.0%); instrumentation (n = 20, 43.5%); research design concerns related to the ability to directly measure a variable of interest (e.g., clinical work, training activities; n = 7, 15.2%); experimenter/researcher effects (n = 3, 6.5%); use of less sophisticated statistical methods (n = 3, 6.5%); and use of an analogue design (n = 2, 4.3%). Within identified limitations, researchers most often cited limited generalizability with regard to sample composition (i.e., lack of diversity, small sample sizes, homogenous samples). Social desirability was noted as a potential limitation given the nature of the topics (i.e., racism, prejudice, privilege). Instrumentation issues pertained to weak reliability for samples, limited validity evidence, and disadvantages of self-administration. Researchers also acknowledged the difficulty of conceptualizing WRI constructs as distinct, noting the multidimensional nature of WRI and the challenge in discriminating between complex constructs.

Key Findings
     There were three main categories of key findings. The largest category (i.e., 51 codes) consisted of identification of correlates and predictors of Whiteness/White racial identity. Findings related to gender and WRI were mixed, with several articles (n = 7) noting differences in WRI stages among men and women (i.e., women more frequently endorsing Contact and Pseudo-Independent stages, men more frequently endorsing Disintegration and Reintegration), and others determining gender differences were not significant in predicting WRI (n = 2). Additional findings included significant positive correlations and predictive effects between WRI, racism, MCC, personality variables (i.e., Openness linked with higher WRI and Neuroticism linked with lower WRI), and working alliance. Other constructs, such as ego defenses, emotional states, social–cognitive maturity, fear, and religious orientation, also demonstrated significant alignment with WRI stages. White guilt, the impact of personal relationships with communities of color, and lower levels of race salience (i.e., race essentialism) were also linked to Whiteness.

The next largest category (i.e., 32 codes) related to critiques of White racial identity models and measures. Most of the conceptual articles focused in some way on this category, often criticizing WRI models as subjective and lacking in complexity, or critiquing WRI measurement and previous research because of issues of reliability and validity. Several stressed caution for interpreting WRI according to existing models, suggesting a more nuanced approach of contextualizing individuals and accounting for within-group variation. Empirical articles also suggested that achieving and maintaining higher levels of WRI, particularly anti-racist identities and attitudes, may be more difficult than originally conceptualized and may require levels of engagement that are difficult to maintain in a racist society.

     Training implications and impact (i.e., 24 codes), noted within empirical and conceptual studies, included tips for addressing Whiteness in counselor education (e.g., offering courses focused on Whiteness and anti-racism) and in supervision (e.g., openly discussing race, privilege, and oppression; matching supervisors and supervisees by racial identity when possible). Empirical studies noted mixed improvement in WRI stages and MCC as a result of both general progression through a counselor training program as well as specific multicultural training: Training was linked to increased White guilt and privilege awareness (n = 15), though others did not find significant effects of training (n = 2). Conceptual articles emphasized focusing training on anti-racist development. Collectively, these findings and subsequent implications encourage further research and reflection on the correlates of WRI and MCC, factors facilitating growth, and ways to improve research and measurement to enhance critical engagement with these topics.

Discussion and Implications

In this content analysis of 63 articles covering a 35-year period across eight national counseling journals, we found that a third of counseling journals featured scholarship specifically related to Whiteness, with the Journal of Counseling & Development and the Journal of Multicultural Counseling and Development accounting for more than 76% of the total sampling units. The majority of the articles were quantitative, followed by theoretical and qualitative articles. Topical focus was centered on correlates of Whiteness with variables such as racism and color-blindness, other non-racial components of cultural identity, training implications, and theory development (see Table 3). Interestingly, many Whiteness constructs discussed in the general literature (e.g., White fragility, modern racism, psychosocial costs) were not addressed in counseling scholarship; the primary constructs discussed were WRI and White privilege.

The sample composition across empirical studies was primarily White and female with a mean age in the late 20s and with undergraduate students comprising on average 22% of the article samples. In addition, practitioners, site supervisors, the general population, and EdS trainees only comprised between 1.6% and 13.1% of the samples. Schooley et al. (2019) cautioned against the overuse of undergraduate students when measuring Whiteness constructs because of the complexities and situational influences of WRI development, and this warning seems to hold relevance for counseling scholarship. Methodological selection mirrored previously found patterns in counseling research (Wester et al., 2013), with most quantitative studies relying upon convenience sampling and correlational design with ANOVA/MANOVA as the selected statistical analyses. In addition, 26.3% of the articles included an intervention. For the qualitative studies, the most frequently used tradition and method was phenomenology and individual interviews.

Overall, findings from the sample support theoretically consistent relationships with Whiteness and/or WRI, including their predictive nature of MCC, social desirability, working alliance, and lower race salience. However, findings were mixed on the role of gender and MCC in connection to a training intervention. Additionally, some studies in our sample critiqued WRI models, cautioning against oversimplification of a complex model and highlighting issues in measurement due to subjectivity and social desirability. This critique aligns with previous researchers who have suggested that WRI is more complex than previously indicated (see Helms, 1984, 1990, 2017). WRI may be highly situational and affected by within-group differences and internal and external factors that complicate accuracy in assessment and clinical application. Of particular concern in previous research is the ability to properly conceptualize and measure the Contact and Autonomy stages (Carter et al., 2004). Both stages have demonstrated difficulty in assessment due to an individual’s lack of awareness of personal racism at each stage (Carter et al., 2004; Rowe, 2006). The Autonomy status, in particular, could be impacted by what DiAngelo (2018) referred to as “progressive” or “liberal” Whiteness, in which efforts are more focused on maintaining a positive self-image than engaging with people of color in meaningful ways (Helms, 2017). Therefore, although there are some consistencies and corroborations within counseling literature and other scholarship on Whiteness, the critiques and complexities of the topic suggest further inquiry is needed.

Implications for Counseling Research
     Based on our findings, we note several directions for future research. First, future studies could include greater demographic diversity as well as more participation from counselor educators, site supervisors, practitioners, and clients across the ACES regions. Including counselor educators in empirical studies can highlight aspects of Whiteness that influence their approach to training and scholarship. With regard to increasing scholarship involving site supervisors, practitioners, and clients, Hays et al. (2019) highlighted several strategies for recruiting sites to participate as co-researchers as well as obtaining clinical samples through strengthening research–practice partnerships. Additionally, recruiting more heterogenous samples—in terms of sample composition and demographics—could provide much-needed psychometrics for available measures as well as refined operationalization of Whiteness. Additional research can further explore individual correlates and predictors to enhance counselor training, supervision, and practice by identifying opportunities for assessment and development at each level of WRI.

Second, most reports of empirical studies in our sample noted concerns with sampling and generalizability, social desirability, and instrumentation. Given these concerns, researchers are to be cautious about the interpretation and application of previous study findings using the White Racial Identity Attitudes Scale (WRIAS). In particular, scholarship within counseling and related disciplines reveals substantial psychometric concerns with the WRIAS’s Contact and Autonomy stages (Behrens, 1997; Carter et al., 2004; Hays et al., 2008; Malott et al., 2015). The complex nature of assessing WRI-related behaviors that may run counter to a person’s intentions (Carter et al., 2004; DiAngelo, 2018) needs further study. Additionally, given the concerns with self-report measures due to socially desirable responses, it seems problematic that none of the current quantitative articles used performance measures, which could help to compare self-report with behaviors and client outcomes. Future research can therefore emphasize behavioral assessments and clinical outcomes to correlate findings with WRI models.

Third, the use of intervention-based research could explore core components of instruction, awareness, and experience to identify facilitative strategies for enhancing WRI in both counselor trainees and within client populations. Because White people are negatively impacted by racism and restricted racial identity, encouraging growth in WRI in both clinical and educational settings can be a means of promoting wellness for counselors and clients. Thus, research is needed that can carefully examine the complexities of WRI development and address difficulties in assessment due to defensive strategies such as White fragility and lack of insight into the various intra- and interpersonal manifestations of racism.

Finally, though the research examined within this analysis advances the application of WRI theory and practices within the counseling profession, opportunities exist for further exploration of WRI development and the intersection with multiple constructs of Whiteness discussed across the helping professions (e.g., White fragility, color-blindness, race essentialism). The articles analyzed for the present study reflect an assumption that more advanced WRI attitudes, lower color-blind attitudes, greater anti-racism attitudes, and greater awareness of White privilege can yield more positive clinical outcomes. However, given some of the aforementioned limitations, this assumption has not been empirically tested in counseling. Because clients’ and counselors’ affective, cognitive, and behavioral responses to Whiteness can affect the counseling relationship, process, and treatment selection and outcomes (Helms, 1984, 2017), it is imperative that this assumption is properly tested. Empirical and conceptual work should therefore further explore Whiteness constructs to elucidate how White attitudes and behaviors at each stage function for self-protection and move toward aspirational goals of anti-racism and ethical and competent clinical application.

Implications for Counseling Practice, Training, and Supervision
     In addition to future research directions related to Whiteness and WRI, findings allow for recommendations for counseling practice, training, and supervision. For example, extant literature emphasizes the importance of racial self-awareness, including an understanding of White privilege and racism. The practice of centering discussions on the harmful impacts of Whiteness, as well as the various ways Whiteness can manifest in therapeutic spaces, allows counselors to examine racial development within and around themselves. White counselors who are able to reflect on their own racial privileges and begin the conversation (i.e., broaching) about racial differences can increase the working alliance quality with clients of color (Burkard et al., 1999; Day-Vines et al., 2007; Helms, 1990).

Furthermore, counselors should heed the themes within the key findings of our sample, following recommendations for taking a broad, contextual, and critical view when understanding and applying WRI models. Counselors can be encouraged to view WRI as Helms (2019) intended—as a broad and complex interplay of relational dynamics, connected with other Whiteness constructs, and following an intentional progression toward anti-racism and social justice. Counselors should take particular caution with viewing the Autonomy stage as a point of arrival, given conflicting findings and the possibility that White people in higher stages may engage in behaviors to assuage guilt rather than to be true allies for people of color. The Helms model associates such attitudes and actions with the Pseudo-Independence stage (Helms, 2019), yet findings cast some doubt as to whether White people who score within the Autonomy stage have actually reached that level of WRI development. Counselors should thus interpret assessment scores with caution and ensure they are also assessing their own level of development and subsequent impact on others through continued and honest reflection and positive engagement in cross-racial relationships.

Regarding training, course content focusing on exploring Whiteness, WRI, and other racial identities through use of an anti-racism training model integrated throughout the curriculum can help students become comfortable with potential cross-racial conflicts and broaching Whiteness (Malott et al., 2015). The Council for Accreditation of Counseling and Related Educational Programs (CACREP) can similarly stress these desired student outcomes when updating standards for counselor training, specifically mentioning the importance of WRI as part of multicultural preparation. It is imperative to begin conversations about race and identity development to create opportunities for growth for any student who may be challenged with their racial identity and how it might impact their clients. Furthermore, counselor educators and supervisors can ask counselors in training to brainstorm how counseling and other services might be developed or adapted in order to contribute toward anti-racist goals and outcomes.

Limitations

The current findings are to be interpreted with caution, as the scope of our study presents some limitations. First, we chose to limit inclusion criteria to national peer-reviewed counseling journals in order to focus on scholarship within professional counseling journals, and therefore our results cannot be generalized to similar disciplines, dissertation research, book chapters, or more localized outlets such as state journals. Our coding sheet was also limited in the information it collected, including sample demographics. Though not all studies included the same demographic variables, we did not capture specifics related to a sample’s political affiliation, religious orientation, ability status, socioeconomic status, diversity exposure, or other details that could have better conceptualized the samples and findings. Additionally, we limited our search to the keywords related to Whiteness that we had identified in related literature but may have missed studies employing constructs outside of our search criteria. Our own identities as White academics may also have influenced the coding process as well as the subsequent interpretation of findings.

Conclusion

This content analysis provides a snapshot of Whiteness scholarship conducted in the counseling profession during a 35-year period. Patterns of study design and analysis were noted, and key findings were summarized to provide context and comparison within the broader literature. Identified themes and relationships highlight theoretically consistent findings for some Whiteness constructs, as well as showcase research gaps that need to be addressed before counselors can apply findings to practice and training. Finally, this content analysis demonstrates the need for a greater understanding of Whiteness and related constructs in counselor education, training, and practice.

 

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

 

References

American Counseling Association. (2014). ACA code of ethics.

Behrens, J. T. (1997). Does the White Racial Identity Attitude Scale measure racial identity? Journal of Counseling Psychology, 44(1), 3–12. https://doi.org/10.1037/0022-0167.44.1.3

Burkard, A. W., Ponterotto, J. G., Reynolds, A. L., & Alfonso, V. C. (1999). White counselor trainees’ racial identity and working alliance perceptions. Journal of Counseling & Development, 77(3), 324–329. https://doi.org/10.1002/j.1556-6676.1999.tb02455.x

Carter, R. T., Helms, J. E., & Juby, H. L. (2004). The relationship between racism and racial identity for White Americans: A profile analysis. Journal of Multicultural Counseling and Development, 32(1), 2–17. https://doi.org/10.1002/j.2161-1912.2004.tb00357.x

Choney, S. K., & Behrens, J. T. (1996). Development of the Oklahoma Racial Attitudes Scale Preliminary Form (ORAS-P). Multicultural Assessment in Counseling and Clinical Psychology. https://digitalcommons.unl.edu/burosbookmulticultural/10

Claney, D., & Parker, W. M. (1989). Assessing White racial consciousness and perceived comfort with Black individuals: A preliminary study. Journal of Counseling & Development, 67(8), 449–451. https://doi.org/10.1002/j.1556-6676.1989.tb02114.x

Day-Vines, N. L., Wood, S. M., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake, K., & Douglass, M. J. (2007). Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling & Development, 85(4), 401–409. https://doi.org/10.1002/j.1556-6678.2007.tb00608.x

DiAngelo, R. (2018). White fragility: Why it’s so hard for White people to talk about racism. Beacon Press.

Frankenberg, R. (1993). White women, race matters: The social construction of Whiteness. University of Minnesota Press.

Hays, D. G., Bolin, T., & Chen, C.-C. (2019). Closing the gap: Fostering successful research-practice partnerships in counselor education. Counselor Education and Supervision, 58(4), 278–292. https://doi.org/10.1002/ceas.12157

Hays, D. G., Chang, C. Y., & Havice, P. (2008). White racial identity statuses as predictors of White privilege awareness. The Journal of Humanistic Counseling, Education and Development, 47(2), 234–246. https://doi.org/10.1002/j.2161-1939.2008.tb00060.x

Helms, J. E. (1984). Toward a theoretical explanation of the effects of race on counseling: A Black and White model. The Counseling Psychologist, 12(4), 153–165. https://doi.org/10.1177/0011000084124013

Helms, J. E. (Ed.) (1990). Black and White racial identity: Theory, research, and practice. Praeger.

Helms, J. E. (1995). An update of Helms’ White and people of color racial identity models. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (1st ed.; pp. 181–196). SAGE.

Helms, J. E. (2017). The challenge of making Whiteness visible: Reactions to four Whiteness articles. The Counseling Psychologist, 45(5), 717–726. https://doi.org/10.1177/0011000017718943

Helms, J. E. (2019). A race is a nice thing to have: A guide to being a White person or understanding the White persons in your life (3rd ed.). Cognella.

Helms, J. E., & Carter, R. T. (1990). Development of the White Racial Identity Inventory. In J. E. Helms (Ed.), Black and White racial identity: Theory, research, and practice (pp. 67–80). Greenwood Press.

Henry, P. J., & Sears, D. O. (2002). The Symbolic Racism 2000 Scale. Political Psychology, 23(2), 253–283. https://doi.org/10.1111/0162-895X.00281

LoMartire, R. (2020). Rel: Reliability coefficients. R package version. 1.4.1. https://cran.r-project.org

Malott, K. M., Paone, T. R., Schaefle, S., Cates, J., & Haizlip, B. (2015). Expanding White racial identity theory: A qualitative investigation of Whites engaged in antiracist action. Journal of Counseling & Development, 93(3), 333–343. https://doi.org/10.1002/jcad.12031

McConahay, J. B. (1986). Modern racism, ambivalence, and the Modern Racism Scale. In J. F. Dovidio & S. L. Gaertner (Eds.), Prejudice, discrimination, and racism (pp. 91–125). Academic Press.

McIntosh, P. (1988). White privilege and male privilege: A personal account of coming to see correspondences through work in women’s studies (Wellesley College, Center for Research on Women Working Paper, No. 189). Wellesley College. https://www.wcwonline.org/images/pdf/White_Privilege_and_Male_Privilege_Personal_Account-Peggy_McIntosh.pdf

Neuendorf, K. A. (2017). The content analysis guidebook (2nd ed.). SAGE.

Neville, H. A., Awad, G. H., Brooks, J. E., Flores, M. P., & Bleumel, J. (2013). Color-blind racial ideology: Theory, training, and measurement implications in psychology. American Psychologist, 68(6), 455–466. https://doi.org/10.1037/a0033282

Rowe, W. (2006). White racial identity: Science, faith, and pseudoscience. Journal of Multicultural Counseling & Development, 34(4), 235–243. https://doi.org/10.1002/j.2161-1912.2006.tb00042.x

Schooley, R. C., Debbiesiu, L. L., & Spanierman, L. B. (2019). Measuring Whiteness: A systematic review of instruments and call to action. The Counseling Psychologist, 47(4), 530–565. https://doi.org/10.1177/0011000019883261

Singh, A. A., & Shelton, K. (2011). A content analysis of LGBTQ qualitative research in counseling: A ten-year review. Journal of Counseling & Development, 89(2), 217–226. https://doi.org/10.1002/j.1556-6678.2011.tb00080.x

Spanierman, L. B., & Heppner, M. J. (2004). Psychosocial Costs of Racism to Whites Scale (PCRW): Construction and initial validation. Journal of Counseling Psychology, 51(2), 249–262. https://doi.org/10.1037/0022-0167.51.2.249

Tawa, J. (2017). The Beliefs About Race Scale (BARS): Dimensions of racial essentialism and their psychometric properties. Cultural Diversity and Ethnic Minority Psychology, 23(4), 516–526. https://doi.org/10.1037/cdp0000151

U.S. Census Bureau. (2020). Public Use Microdata Sample data. https://www.census.gov/programs-surveys/acs/data/pums.html

Wester, K. L., Borders, L. D., Boul, S., & Horton, E. (2013). Research quality: Critique of quantitative articles in the Journal of Counseling & Development. Journal of Counseling & Development, 91(3), 280–290. https://doi.org/10.1002/j.1556-6676.2013.00096.x

 

The authors would like to thank Cheolwoo Park for his invaluable assistance in this study. Hannah B. Bayne, PhD, LMHC (FL), LPC (VA), is an assistant professor at the University of Florida. Danica G. Hays, PhD, is a dean and professor at the University of Nevada Las Vegas. Luke Harness is a doctoral student at the University of Florida. Brianna Kane is a doctoral student at the University of Florida. Harness and Kane contributed equally to the project and share third authorship. Correspondence may be addressed to Hannah B. Bayne, 140 Norman Hall, Gainesville, FL 32611, hbayne@coe.ufl.edu.