Marissa Meyer, Elizabeth Wiggins, Gregory M. Elliott
In this transcendental phenomenological study, we interviewed seven adult adoptees regarding their lived experiences of growing up as an adoptee and how this shaped their perception of loss, grief, and counseling in relation to their adoption. Our analysis revealed an overarching concept of the level and manner with which the participants integrated their adoption story into their life narrative and whether loss, grief, and working with a counselor were significant integration factors. As a result, six themes emerged, including ambivalence toward loss and grief, how one’s adoption story was impactful, issues with connection, identity curiosity, relational distrust, and involvement with counseling. We discuss these ﬁndings and identify implications for counselors working with adoptees.
Keywords: adoption, loss, grief, integration, ambivalence
There is a growing recognition that the adjustment of adoptees is an important area for further research (Cashen & Grotevant, 2020; Liu et al., 2019). It is estimated that over 100 million Americans are connected to adoption in some manner (Jones & Placek, 2017). Miller, Fan, Christensen et al. (2000) have suggested that higher numbers of adopted persons seek counseling than non-adopted persons. Research also shows that adult adoptees value counseling experiences that address adoption-related topics (Baden et al., 2017). Yet, little is known about the adult adoptee’s experience with counseling, loss, and grief (Côté & Lalumière, 2020). Given the rise of adoption in the United States and counseling needs of adoptees, counselors are likely to encounter an adult adoptee during their career. Gaining a deeper grasp of the impact of adoption on adult adoptees’ mental health and potential distress in adulthood is an important consideration for counselors (Côté & Lalumière, 2020; Liu et al., 2019; Miller, Fan, Grotevant et al., 2000).
One important aspect of exploring adult adoptees’ experiences with mental health and counseling is understanding how they experience and process feelings of loss and grief related to their adoption. When addressing the topic of loss, at a rudimentary level, it can represent familial and relational loss due to separation from one’s biological roots. For some, this occurs not long after birth, which can influence how one adapts psychologically (Cai et al., 2020). For years, researchers have explored the impact of adoption, notably during childhood and adolescence, with an emphasis on psychological adjustment and mental health compared to non-adoptees (Melero & Sánchez-Sandoval, 2017; Miller, Fan, Christensen et al., 2000). Yet, research is limited concerning lived experiences from adult adoptees’ perspectives on how they progressed from a psychosocial standpoint over time (Melero & Sánchez-Sandoval, 2017), in addition to how the distinctive loss(es) they incurred impacted their lives. In one study addressing how adult adoptees navigated adulthood developmental tasks, the researchers acknowledged loss as a predominant theme and recognized it might not be well understood until middle adulthood (Penny et al., 2007). Neil (2012) similarly validated the notion that loss may be too complex for children to comprehend wholly. As adoptees developmentally transition from childhood through adolescence and then into adulthood, their perception of adoption and their identity formation likewise evolve. Researchers have suggested the integration of what it means to be adopted is continual for adoptees over their lifetime (Field & Pond, 2018). This is another reason why considering the perspectives of adult adoptees is important, as adults may have a more mature ability to process and understand the concept of loss on a meaningful level.
For this study, our operational definition of loss was separation from one’s family of origin, including absence of knowledge about, and relationships with, birth parents and families. This may result in a grief response toward these losses, manifested via sadness, anger, denial, depression, and other complex emotions. Each person’s story is unique and for some adult adoptees, loss is a central theme due to the obvious separation, which may disrupt their capacity to connect, leaving them susceptible to relational difficulties (Field & Pond, 2018; Liu et al., 2019). However, some adult adoptees perceive this loss ambiguously because of an atypical separation, meaning the exposure to loss was experienced under abnormal or non-ideal circumstances. Examples of these atypical separations with the birth parent(s)/family could include socioeconomic status, educational level, complicated dynamics (e.g., inability to handle another child, rape), or being in the public care system (O’Leary Wiley & Baden, 2005). Notwithstanding the reason(s) a birth parent(s) decides not to raise their biological child, an obvious loss occurs due to separation from at least two primary, biological relatives. In Westernized culture, tangible losses are naturally recognized, such as death to illness (Brodzinsky, 2011), whereas less concrete losses, or intangible losses, go unacknowledged (Wright, 2009). Intangible losses can produce a feeling of disenfranchised grief, particularly for adoptees. Intangible loss is typically overshadowed by what a person has retained or gained, and in the case of an adoptee, the gain is a family, with associated feelings of permanence and security (Brodzinsky, 2011).
Because the processing of loss can be a central theme in a person’s adoption narrative and throughout the natural life span, it is likely this can surface for an adult adoptee within the therapeutic setting. Loss of biological parents and genealogical continuity are just two elements tied to an increased risk for psychological disorders (Côté & Lalumière, 2020). Additionally, qualitative studies exploring the lived experience of adult adoptees, such as this study, shed light on participants’ perception of loss, the handling or dismissal of grief, and whether counseling has been, or could be, a source of support.
Impact of Adoption
It is not surprising that adoption impacts a person’s life on multiple levels, merely because of the complexity of relationships and human nature. Recognition of both positive and negative facets of adoption is important because denial of grief and the inherent aspect of discontinuity with this life event can interfere with the generation of a healthy life narrative (Wright, 2009). According to Soares et al. (2019), adoptees experience both gains and losses/difficulties. A significant gain is what the researchers referred to as family experience, meaning the adoptee was provided an opportunity to have parents and maybe siblings, whereas the dominant difficulties were discomfort around conversations about adoption and adapting to the adoptive family relationships (Soares et al., 2019). This information highlights the intricacies of how adoption can affect both connection and disconnection among relationships for adoptees. Anderson et al. (2015) highlighted how varying views (i.e., acknowledgment, rejection, or discrepant) regarding the significance of communication around ethnic differences among international adoptive families impacts the level of engagement and familial cohesiveness. On another note, Soares et al. (2019) examined perceived losses in child research participants, with results showing only 32.4% of children interviewed as identifying with birth family loss. The researchers noted that even in positively viewed adoption experiences, there needs to be recognition that children may not be in an environment in which they can acknowledge and grieve their losses (Soares et al., 2019). That study, however, did not extend its results into the realm of adulthood by observing how adults experience the impact of adoption losses and subsequently grieve those losses.
Another common topic concerning adoption is mental health, and Lehto et al. (2020) studied the relationship between being adopted as a child and the mental health of adoptees in adulthood, with respect to phenotypic (genes plus environment) and genetic factors. The results pertaining to phenotype, or observable characteristics, revealed no significant differences between adoptees and non-adoptees regarding general life and relational satisfaction, although their data also suggested adoptees were more susceptible to depression, schizophrenia, and neuroticism compared to their counterparts (Lehto et al., 2020). In an earlier article, Brodzinsky (2011) shared clinical case scenarios of child adoptees and their respective parents to examine identity and psychological adjustment issues that arise, including both pre-placement factors (e.g., genetics, unfavorable birth parent conditions) and how adoptive parents navigate conversations about adoption. Yet, within this research, there was a dearth of qualitative, lived experience research data concerning mental health issues present in adult adoptees, including any possible instances of unidentified loss and, in turn, unresolved grief.
In adoption, loss(es) ranges from separation from one’s biological family to losing one’s cultural heritage and identity. Boss (2010) explored the notion of two types of ambiguous loss—one tied to a physical absence, and one tied to a psychological absence that precluded closure for adoptees. For example, it is considered common knowledge that some adoptees have likely created a fantasy of their biological parent(s), but if they lack information about their genealogy (due to closed adoption or no contact with birth relatives), what remains are assumptions and questions. Thus, adoption is an example of ambiguous loss, with symptomatology that can include depression, anxiety, and feelings of ambivalence due to the scarcity or absence of information and potential for closure (Boss, 2010). Although this research explored symptoms of ambiguous loss tied to adoption, it did not address adoptees’ experience with loss and grief work in counseling.
Although there is adoption research exploring the topic of loss, there is minimal literature incorporating the lived experiences of adult adoptees. For adult adoptees, loss is distinctly a part of their life story, including hypothetical aspects of one’s identity, sense of control, and possible sadness over not being biologically linked to their adoptive family, all of which may be presented in counseling (Corder, 2012). Corder’s (2012) research was to assist counselors in their work with adoptees, including briefly addressing loss and grief, yet it did not delve into the lived experiences of adult adoptees concerning these topics.
Purpose of the Study
In summary, there is a recognition of the need for more research on the counseling needs of adults who were adopted as children because of both the growing number of Americans who have been touched by adoption and the underrepresentation of the needs of adult adoptees in the research literature (Cashen & Grotevant, 2020; Côté & Lalumière, 2020). Therefore, we set out to explore the lived experiences of adult adoptees regarding their perspectives of loss and grief resulting from their adoption, including any involvement with counseling. In a comprehensive content analysis of adoption articles in counseling journals, Liu et al. (2019) found 45 articles on the topic spanning 30 years, and only 10 of those articles (22%) investigated adults who were adopted as children. Literature on adoptees has largely focused on children and adolescents, specifically regarding their psychological adjustment and mental health compared to non-adoptees (Miller, Fan, Christensen et al., 2000; Soares et al., 2019). Researchers have suggested that loss is an important aspect of the adoption experience needing more exploration (Corder, 2012; Liu et al., 2019; Neil, 2012; Penny et al., 2007), but to date the research on loss as part of the adoption experience has largely been explored quantitatively (Field & Pond, 2018). Despite the assertion that grief is a significant aspect of a child’s adoption story that extends into adulthood (Wright, 2009), we found a minimal amount of qualitative published literature exploring the impact of adoption and associated feelings of loss and grief on adult adoptees.
Our study was guided by our research question: What was the lived experience of adult adoptees regarding loss, grief, and counseling as it related to their adoption experience? We implemented a descriptive, qualitative research design utilizing a transcendental phenomenological methodology to explore these topics from an inquisitive standpoint. Transcendental phenomenology encourages researchers to suspend preconceived judgments about a subject and adopt epoche or intentional bracketing (Moustakas, 1994). This phenomenological concept has researchers bracket presumptions about the phenomenon being studied, which allows for transparent reflection and an ability to view the research data with a fresh perspective (Moustakas, 1994). By utilizing this approach, the reality of the participants’ lived experience of adoption, loss, grief, and counseling could be deeply surveyed to produce a true meaning of the phenomenon. In this qualitative approach, there is a correlation between the what, or the noema, of the experience, and how something is experienced, or the noesis (Sloan & Bowe, 2014).
The research team consisted of one full-time counselor, Marissa Meyer, who identifies as Latina, and two full-time counselor educators, Elizabeth Wiggins and Gregory M. Elliott, who identify as European American. Meyer is an adoptee, Wiggins has no affiliation with adoption, and Elliott’s first child is a child by adoption.
We submitted the study protocols through the IRB of the university where we were all engaged, as either a student or professor. Once approval was granted by our institution’s IRB, we transitioned into the participation selection process. Inclusion criteria were that participants be adults who experienced adoption as children and were willing to share their perspective of loss and grief pertaining to their adoption experience. Additionally, we vetted adoption-competent counselors as referrals to provide to participants, in the event they were triggered.
We utilized a purposeful, snowball sampling procedure to select participants. We advertised the study regionally to Colorado adoption agencies and counseling centers offering services to adoptees. Potential participants were referred to the study by current participants. Prospective participants who responded to the advertising contacted Meyer by email and were subsequently scheduled for screening. Our initial contact with the potential participants was conducted via email, which included the invitation to participate and a link to a brief survey. The survey included criterion questions to capture the participants’ demographic data and perceived level of loss and grief via a 5-point Likert scale (see Table 1).
|Age at Adoption
|After 9 Months
|Initially Placed in Foster Care
|Learned Was Adopted as a Kid
|Contact With Birth Family
|No Contact With Birth Family
|5-Point Likert Scale Ratings of Loss/Grief Toward Adoption w/ 1 (minimal)–5 (extreme)
Nine prospective participants responded to study advertisements and during the initial screening the final pool was narrowed to seven, with one respondent not meeting the inclusion criteria and another one withdrawing from communication with the research team. The final seven respondents accepted the invitation to participate and were emailed the informed consent form to formalize their participation status. The participant sample included four males and three females, and the ethnicity/race breakdown identified by each participant was: one Asian American, three White, and three Hispanic/Latino(a). Six of the adoptions were domestic and one was international (see Table 1). Smaller sample sizes and lack of randomization are common with phenomenological studies because of the level of data analysis and the need for participants to share a common experience (Nicholls, 2009). We assigned participants pseudonyms for confidentiality (Sheperis et al., 2017), which were used in the analysis and writing processes.
The goal of transcendental phenomenology is to describe the essential structures of the participants’ lived experiences around a particular phenomenon (Barnes, 2003) as opposed to analyzing data for the purpose of generalization to broader populations. It can be conceptualized as a “science of examples” (Van den Berg, 1955, as cited in Farrell, 2020, p. 5). Therefore, recruitment of participants is based on finding diverse participants whose lived experiences illustrate the phenomenon being studied. Published studies utilizing a phenomenological methodology have utilized samples ranging from three (Pretorius & Hull, 2005), to six (McCaig et al., 2012), to many more. We felt we achieved saturation with the seven participants given the breadth and diversity of their adoption experiences.
Data Collection Measures
Qualitative research inquiries are emergent, making interviews and semi-structured interviews common methods of data collection (Levitt et al., 2021). We developed four foundational interview prompts to frame our interviews based on our initial meetings to develop the research protocols and on our literature review. The foundational interview prompts were designed to ground the interviews in the phenomenon of study and to allow space for semi-structured exploration based on participants’ responses. Prior to beginning interviews with our participants, we engaged in an epoche process (Moustakas, 1994), by having Meyer (an adoptee herself) answer the foundational interview prompts. Meyer’s responses were analyzed and referenced throughout the data analysis process. We then conducted phenomenological semi-structured interviews individually with each participant. The four foundational interview prompts were: 1) describe your experience with adoption and how it has played out in your life, 2) recount your experiences with counseling related to adoption, 3) tell me how your adoption narrative has influenced your perceptions of loss and grief, and 4) share how you feel your grief has been or not been expressed over your adoption-related losses. The semi-structured interviews supported flexibility and helped ensure the participants could fully share their stories (Levitt et al., 2021). Thus, the semi-structured interviews helped us understand the participants’ adoption stories and their experiences with grief, loss, and counseling.
We conducted and recorded interviews via Zoom video conferencing technology. Then we manually transcribed the recorded interviews into transcripts via Microsoft Word. For participant anonymity, the assigned pseudonyms were used during the transcription process. After the transcription and data analysis, all video recordings were destroyed to protect participant confidentiality, and only the pseudonyms were utilized in the manuscript.
We initiated thematic analysis by following Moustakas’s (1994) process of phenomenological reduction to analyze the data. Thus, we each explored and analyzed our unique experiences with adoption that allowed us to transcend any presumptions regarding the phenomenon being studied by implementing the concept of epoche (Moustakas, 1994). As noted earlier and regarding closeness with adoption, Meyer was adopted as an infant, Elliott has adopted a child, and Wiggins has no experience with adoption. Therefore, the thematic analysis and epoche process included Meyer’s answers to the research questions. Lastly, the examination of our experiences with the phenomenon were considered in the research findings as part of the transcendental phenomenology view of researchers and participants working together as “co-researchers” (Creswell, 2013; Moustakas, 1994).
We transcribed the interviews and analyzed the participant phrases via an Excel spreadsheet to ascertain themes. Then, we engaged in an initial holistic reading of each interview transcript to allow ourselves to be attuned to each participant’s words. Next, we performed a line-by-line reading and formulated a list of “significant” statements and grouped them into “meaning units” (Creswell, 2013). Transcendental phenomenology seeks to find meaning units that provide a textual description of what was experienced by the participants, as well as an imaginative variation describing how it was experienced (Moustakas, 1994). With each distinguishable reading of the data, we searched for phrases shared by the participants that illustrated a description of what they experienced and how it was perceived. Ultimately, through a process of consensus coding, the integration of the textual description and the imaginative variation yielded a composite of essential themes.
After we analyzed and narrowed down the dominant themes via the final transcription phase, we emailed the participants these preliminary findings. We asked the participants to reflect and provide feedback on whether the final themes represented their experiences with adoption-related loss and grief, as well as their experiences with counseling related to adoption, as a form of member checking (Creswell, 2013). The participants confirmed that the findings adequately expressed their experiences with adoption-related loss, grief, and counseling.
Qualitative researchers promote trustworthiness in their work by safeguarding the credibility and confirmability of their methods and findings (Cope, 2014). Credibility is viewed as the direct connection between the participants’ words and the findings of the study (Cope, 2014). Confirmability is the level to which interpretation of the texts are representative of the participants’ meanings rather than the researchers’ preconceptions or bias alone (Cope, 2014). In this study, we ensured credibility and confirmability through immersion in the texts and by developing a spreadsheet that we utilized to track the analysis process of transforming the participants’ words into themes. This audit trail allowed us to revisit the data when questions of interpretation arose and as we worked toward consensus in our interpretation, as opposed to relying on any one researcher’s sole interpretation (Hill et al., 2005). In addition, we utilized member checking to test the goodness of fit of the findings and interpretations of the participants’ lived experiences to minimize researcher bias (Cope, 2014; Sheperis et al., 2017).
Our analysis brought to our awareness the concept of integration regarding the participants’ adoption stories, meaning to what depth the participants’ adoption experiences impacted their perceptions of loss, grief, and their involvement with counseling. Expanding on this and in alignment with the initial participants’ survey results regarding the perceived level of loss and grief toward their adoption (see Table 1), it was clear the prominent theme was that of ambivalence of whether loss and grief were significant aspects of their adoption story. Under this notion of integration, we identified six themes that expressed our participants’ experiences. The central theme was ambivalence toward loss and grief, followed by identity curiosity, the impact of one’s adoption story, connection, relational distrust, and involvement with counseling.
Ambivalence Toward Loss and Grief
This first theme regarding uncertainty toward loss and grief was significant, as it closely touched on the study’s research question and the participants’ perception of these two topics in relation to their adoption. Thus, it established the degree to which loss and grief were associated with and/or processed in the context of being adopted. Some of the participants indicated they did not feel they had undergone measurable loss and grief explicitly tied to their adoption experience. For example, Martin stated that he is “not an emotional person, [so] I really don’t have a huge amount of grief.” Similarly, Teresa stated, “I think the reason that I don’t personally feel, and haven’t really ever felt, a ton of loss is because of the strategies my mom used.” Teresa explained that her adoptive mother’s intentionality regarding her processing and normalizing her adoption story helped Teresa not struggle emotionally with her adoptee status.
However, most participants relayed a personal story of loss and grief that they initially believed did or did not relate to their adoption, which iterated the sense of ambivalence from the participants when asked about loss and grief in association with their adoption experience. For example, even though Martin expressed not having feelings of loss and grief related to his adoption, when he discussed the loss of his adoptive parents, he was struck with a sudden, profound feeling of emptiness: “After my [adoptive] parents passed away, it was like, okay, now I need to fill that void to see where I really come from.”
In contrast, Tonya saw how her feelings of loss and grief were directly related to her adoption: “I guess I just experienced loss at a younger age than most people probably would. Because I had to learn how to let go of something I didn’t even know. Someone I didn’t even know.” Mike echoed Tonya’s feelings about the immense ache of missing a person he had never known, his birth mother. The realization that he was grieving the loss of his birth mother initially hit him when he was processing the loss of a romantic relationship:
I think that mother aspect was really something that was powerful in that moment. . . . That moment stayed with me. Because I realized that was the night that I finally started to grieve the loss of my [birth] mom. And I started to realize, it’s OK. She’s out there, and you’re out here, and you’re OK with being sad for her, and finally, someone opened the door for me to do that.
Teresa, whose potential struggles with loss and grief were alleviated by her adoptive parents’ openness in talking about her adoption story, shared some sadness related to her adoption. She stated that she mostly thought about the parent who gave her up. She wondered about the impact on her biological mom, sharing “What if it was really hard for my mom? Or what if I had a sister out there who misses me? Or a brother or something?” Her expression of grief and loss was more around the questions to which she did not have answers.
All the participants were able to discuss aspects of loss and grief, as would be expected, because they are existential elements of the human experience. In interviewing the participants and reviewing their transcribed stories, it appeared that some of them had potentially never processed the idea that they could have experienced sensations of loss and grief related to their adoption, and the research interview was the first time they had been confronted with the idea explicitly. However, most of the participants were ultimately able to connect some loss and grief feelings to their adoption status or experience.
Another notable theme was an expressed desire for the participants to understand who they are as human beings—to clarify their identity since being adopted. The seven participants varied in the amount and timing of the information they had about their adoptions as children. One participant, Teresa, poignantly shared how her adoptive mother would tell Teresa’s adoption story at bedtime, including being adopted from Korea without identifying information of her birth family. In contrast, Luke relayed that his adoption was revealed to him by a vindictive cousin. However, regardless of the amount of information the participants knew about their adoptions as children, as adults, most of them made some reference to intentionally working toward discovering and understanding who they are.
For example, Mike reflected on where some of his personality and emotional traits stemmed from:
I saw things that my dad would do, or my mom would do, and I would do the exact opposite of what they were both doing. [And I would be] like, “where am I getting this from?” You know, I don’t pick this up from either of them . . . I’m not part of them, so where’d I get this stuff that I do?
Carla expressed sadness that when her adoptive parents died, she lost the possibility to learn more about her birth circumstances and identity. She expressed still feeling curiosity surrounding her identity as well as regret and bitterness associated with losing any potential of having questions answered by the people who were there when she was adopted.
I had four parents I guess, and they’re all gone, and that just hit me as incredibly sad that I will never know. I’d always hoped she [adoptive mother] would come forth and be honest about what it was, what happened. I don’t know if she didn’t know, or if she just blocked it, or she was refusing. I don’t know, but with her died my story.
The participants largely positioned their identity curiosity as a response of being an adoptee with an implicit assumption that if they were not adopted, some sense of self-identity would have been granted to them by their birth parents.
Impact of Adoption Story
This theme acknowledged that all the participants expressed in at least one way how their adoption story impacted their overall life narrative. The level of impact varied between the participants, but they all recognized their status as an adoptee was a significant component of their personhood. Ivan expressed that despite knowing his whole life he was adopted, he never had a desire to connect with his birth parents and never considered his adoptive parents to be anything other than his “real” parents. Even with these views, Ivan related a compelling adoption story of his birth mother being talked out of aborting him during a smoke break while she was waiting at the abortion clinic. Ivan felt this brush with almost having his life terminated had put a special meaning on his existence.
The fact that I was minutes away from being aborted just always placed some sort of significance in my life where I say “I can’t waste my life.” . . . It’s given me a proponent to excel in life because if I was saved for a reason, I have that mentality in the back of my head because I know that story.
Tonya also expressed a tumultuous adoption story that involved several years in which she tried to contact her biological mother. Tonya indicated that her adoptive parents “had always told me that I was adopted, but I don’t really think I understood when I was little what that all meant.” However, the knowledge of her status as an adopted child did eventually impact Tonya’s relationship with her adoptive mother as she grew up. She experienced anger toward her adoptive mom, stating that she had thoughts of her “not being my real mom.” But she is grateful that they were able to carve out a close relationship over time.
Participants roughly characterized if they felt their adoption had been smooth or difficult. However, whether the participants felt positively or negatively about their adoption, they all acknowledged the experience of being an adoptee has been an important aspect of coming to terms with their identity. Overall, they felt it was an essential component of their life story.
Several of the participants recognized they had difficulties connecting with others, and they attributed these difficulties to being adopted. Some participants expressed struggles among immediate family members, such as their own biological children, while for others, issues were localized to social situations. Yet, on a larger scale, some participants’ struggles were characterized as being global. For example, Luke stated, “I certainly always have, more often than not, viewed myself negatively . . . lots of self-doubts in terms of self-worth, very negative feelings, just not good enough. And super-sensitive to the perceptions and judgments of others, and particularly rejection.” These feelings led him to allow boundary violations and being taken advantage of in order to “please, placate, and satisfy the needs of others.”
Like Luke, Carla expressed difficulties with connection and relationships that had persisted for most of her life. Carla spoke poignantly of her difficulties with “attaching” to anyone or anything, except for her own biological children:
I’ve always been kind of a searcher . . . I’m searching for a home, searching for a place, searching for a person, searching for something. Though I’ve moved around the country, I’ve moved from house to house, I’ve moved from apartment to apartment, I’ve moved from boyfriend to boyfriend, I’ve moved from husband to husband, and I’ve moved all over trying to find something, which I never did. And I always kind of explained it like a piece of floating chain in the air and all the posts are standing on the sidewalk down below, but I’m not attached to any of them . . . even when I had my own children, I just kind of added their link onto mine, so then we were just free-floating a couple of links instead of by myself. I never had anything to attach to.
Teresa discussed how social connection specifically was complicated for her growing up because being an international infant adoptee raised by White parents meant she was racially different than her family:
I remember being really self-conscious in high school about, you know, I would see a lot of people [of my race] who had recently immigrated to [the state where I lived]. And I clearly didn’t fit in there. And then I had all of these very White people, and I was like, “I don’t know if I fit in with them either.” And so, it was like this awkward, “where do I fit?” kind of situation. But I think part of why I didn’t try immersing myself more in [my birth] culture was because I wanted to be more in the mainstream White, American culture; that’s kind of how I identified as culturally. I know racially I wasn’t.
As illustrated by Luke, Carla, and Teresa, the participants possessed a deep desire for connection with others, but factors related to their adoption made this challenging at times.
Because of the occurrence of some participants noting that they continually struggle to trust others in relationships and certain social circumstances, this theme was notable. In our analysis, we recognized some overlap between this theme and the theme of connection, but we felt there were enough specific mentions of distrust to position it as its own theme. Luke reflected on this theme of not being able to trust others when he processed his feelings of low self-worth, which he attributed to his adoption circumstances:
You can go through all kinds of rationalizations, and probably a lot of true thinking about the realities of what led to this, and at the end of the day, you come back to that same conclusion—someone didn’t love me, someone didn’t want me, I was rejected, I’m unlovable, you know, you come back to that. And you sit in that, and that’s what you believe. And no one’s going to tell you any different.
It is worth noting that Luke was one of the few participants who stated that his adoptive parents were not honest with him about his status as an adoptee from early on in his life. Luke related first being told he was adopted by a cousin who was taunting him, and Luke’s processing of his identity included some significant challenges to obtain valid information about the circumstances of his birth and adoption. In further discussing this with Luke, he expressed, “Here’s another dead end, or another misinformation, or whatever it is, and I just kind of gave up on that. I will tell you, that creates anger and resentment and loss, and it’s a real double-bind.”
In exploring his adoption story, Ivan also reflected on distrust and noted that “When you feel some sort of deception or some sort of awkwardness, that’s what tends to, at least for me, want to dig more and see if there’s something that they’re hiding or something underneath that.” Some of the participants adopted an investigative role in trying to track down information on their birth and adoption. For the participants who related this mission of exploring their roots, the theme of relational distrust occasionally presented itself in the frustrations of pursuing false leads and overcoming dead ends in the search for their origin stories.
For Tonya, however, the theme of relational distrust showed up as not trusting that she could be accepted or loved if she didn’t perform perfectly. She struggled with accepting Bs in middle and high school, having to remind herself that “B doesn’t mean bad.” Admittedly, she had to work on her self-esteem. She shared that she felt insecure and that she had to “prove [she] was worth something.” For Tonya, her sense of distrust was seemingly rooted in a self-concept of inadequacy, a feeling that was echoed by Luke, Mike, and other participants.
Involvement With Counseling
Participants in this study also explored their experience with counseling. These contacts ranged from intense, long-term therapeutic work to a psychological interview prior to being allowed access to adoption records. Although there was significant variation in how much benefit the participants ascribed to this therapeutic contact, the fact that all seven of the adoptees had initiated work with a mental health professional was notable.
The participants’ varied responses when asked about counseling as it related to their adoption brought to our awareness this theme that depicts the perceived applicability of engagement with therapeutic services. We discovered that all participants had some level of involvement in working with a counselor.
Carla was one of the participants who sought out counseling with multiple clinicians over the course of several years. She summarized her attempts to connect with a counselor this way:
I’ve done a fair amount of counseling over the years. Most of it was not with anybody who was adoption savvy. . . . And it really hasn’t stuck until 4 years ago when I started the adoption group and the therapist there is an adoptee as well.
Tonya reflected on her experience with counseling as eventually being beneficial. She shared how she began her experience with therapy at a young age and how she eventually received her diagnosis through the counseling process. She expressed that having a good counselor was important to her and recalled one counselor that she just “clicked with right away.”
Luke’s experience with counseling started later in life. He shared that the impetus for seeking out a counselor was not specifically geared toward his adoption. Instead, he found himself seeking counseling related to his “whole person,” noting that although it wasn’t specifically related to adoption, he recognizes that it is “part of the story, and that’s part of what informed so much of my self-perception.” In contrast, Martin relayed that counseling has not been necessary, stating “I haven’t had any major issues, so I haven’t needed counseling.” He limited his exposure to counseling to a 1-hour interview with a psychologist after requesting adoption records.
As shown by some participants, therapeutic involvements were distinct and ranged in need, intensity, adoption relevancy, and perceived benefit. Additionally, several participants indicated a preference for a counselor who was competent in matters of adoption to be sure they were properly cared for and understood in the therapeutic environment. Although mental health professionals are trained in multicultural competencies to be able to provide help and support to clients who are different from the counselor in demographic characteristics and lifetime experiences, the inclusion of adoption experiences should be considered within this realm.
This study revealed if and/or how the participants integrated aspects of their adoption story into their perception of loss and grief, and whether counseling played a role in this process. Ambiguity toward loss and grief was of utmost significance given the impetus for our research study. When posing questions to our study participants regarding their experiences about grief and loss, they relayed mixed responses or ambiguous feelings. Interestingly, Powell and Afifi (2005) define adoption as an ambiguous loss, stating that adoption is associated with the physical loss of the birth parents’ presence in an adoptee’s life, but that there remains a psychological presence that can cause ambiguity in an adoptee’s life. Mitchell (2018) suggested ambiguous loss can be the most traumatic type of loss because the grieving process is often overlooked. Unacknowledged grief may be why our participants experienced ongoing ambiguity around the topics of grief and loss.
The themes of identity curiosity and impact of one’s adoption experience were complementary to one another, which was apparent when our participants shared how they have viewed these topics both in the past and now as adults. Chatham-Carpenter (2012) conducted a study on the impact of an adoption narrative on Chinese adopted children, stating that “As human beings, our identity, or sense of who we are and what our place is in the world, is formed through the telling of narratives or stories” (p. 159). The same seemed to be true of our participants, as they were impacted by positive and negative narratives, as well as by the way they were told about their adoption. Our participants, like those in the Chatham-Carpenter study, were also curious about their identity. Erikson (1968) researched the development of one’s identity and posited that this occurs in stages. A significant life event, such as adoption, during an early stage of development can lead to an unhealthy or underdeveloped sense of self.
There was a moderate overlap between the themes of connection and relational distrust, which afforded us a deeper understanding of the participants’ adoption narrative. For example, our participants revealed struggles connecting with others, supporting existing research that shows people who have been adopted often struggle to form relationships (DeLuca et al., 2019), and that the quality of relationships with adoptive families is an influential component of the ability of adoptees to form healthy connections with others (Melero & Sánchez-Sandoval, 2017). As it pertains to relational distrust, our findings were similar to the Shahab et al. (2021) study, which found that adults with a history of childhood maltreatment are more likely to experience distrust; feel distant from others; and develop an insecure attachment style, which may also affect relationship quality.
Our final theme concerning involvement with counseling connected to the notion of adoptees potentially experiencing ambivalence regarding how they feel toward their adoption experience. Our participants expressed a wide range of information regarding their reasons for seeking out counseling, as well as the prominence of the topic of adoption within the therapeutic setting. Thankfully, the need for adoption-competent counselors has been the subject of numerous studies (Baden et al., 2017; Evan B. Donaldson Adoption Institute, 2010; Freundlich, 2006; Lenerz et al., 2006), and our participants echoed this need for someone who could understand their experiences and help them explore the impact adoption had on their lives. Baden et al. (2017) found that adoptees in counseling reported greater satisfaction in proportion to the amount of attention the therapist paid to the topic of adoption.
This study explored the experiences of adoptees with counseling, loss, and grief, leading to important implications for professional counselors. Counselors should recognize that adoptees value mental health professionals who address the topic of adoption and are competent in working with clients who are adoptees. Counselors working with adoptees may benefit from treating a client’s adoptee status as an area of multicultural diversity and studying the relevant literature to help develop competence (Remley & Herlihy, 2020). Being more aware of the challenges adoptees experience integrating loss and grief into their life narrative could help a counselor successfully engage with such clients. An ability to address these intricacies through a relationally oriented counseling technique such as existential therapy’s here-and-now processing approach (Yalom, 2002) might be warranted. Additionally, it is important to recognize that grief is a unique process for everyone, including every adoptee. Grief that arises from a recognition and acceptance process when coming to terms with one’s adoption is likely to be complex and interwoven with accepting the fact and circumstances of one’s adoption. A narrative therapy approach could offer clients an opportunity to re-author both their adoption story (unique and alternate outcomes) and the future story they want to have (White & Epston, 1990). Kessler (2019) suggested that a sixth stage of grief (added to the traditional stages of denial, anger, bargaining, depression, and acceptance) is finding meaning, and this additional stage would appear to be resonant in the lives of virtually all of our study’s participants.
The findings and discussion of this study should be considered within the context of its limitations. One limitation is the sample used by the researchers. The study included seven purposefully selected participants to represent adult adoptees, including four males and three females, and more minorities than White participants. The U.S. Department of Health and Human Services (2020) reported that White children (50%) are adopted at approximately the same rate as other ethnicities, and male children (51%) are adopted slightly more frequently than female children (49%). Although this study’s sample is representative of the current racial and gender makeup of adoptees, expanding on the diversity of participants could make for a more robust description of the lived experiences of adult adoptees.
Another study limitation is the use of self-report interviews for data collection. Using interviews alone, participants may be influenced by social desirability, which may impact the credibility and dependability of the data collected (Heppner et al., 2008). At each interview, the researchers encouraged participants to share their unique experiences. Yet, participants may have felt compelled to respond in ways viewed as desirable to the researchers, society, or the profession of counseling. In the future, this limitation could be addressed by increasing persistent observations. This would allow for the researchers to determine if the responses to the interview protocol remained consistent over time, thus increasing the study’s dependability.
Recommendations for Further Research
Further research around the notion of integration of one’s adoption story into a person’s life narrative by exploring our six identified themes via the lived experiences of adult adoptees could benefit the profession of counseling. We recommend continuing research in this area while expanding the diversity of participants being studied. One possibility could be a grounded theory study that explores the process of identity development for adoptees. Although this study identified themes of deep curiosity about oneself and being impacted (either positively or negatively) by adoption, we were not able to establish causal relationships between the status as an adoptee and these intrapersonal traits. A larger, quantitative study might be able to further explore these issues and determine a causal link between adoption and the development of these intrapersonal characteristics.
Another identified theme was adult adoptees’ involvement with counseling and what each participant’s situation entailed. Although the interviews contained questions that explored the participants’ counseling experiences, this study did not specifically focus on what adoptees valued in counselors. Further research could utilize more explicit questions regarding this topic, including interventions that counselors draw from to build a strong therapeutic alliance with clients who have been adopted.
Finally, creating a research design to further explore the themes of connection and relational distrust is important in understanding the relational impacts of adoption on adoptees. Research on these topics may lead to more effective counseling techniques and goals for adoptees and families, along with common challenges for families considering adoption.
We explored the lived experiences of adult adoptees to grasp and understand their perceptions of loss, grief, and their involvement with counseling in relation to being adopted. Our findings suggested a common theme of ambivalence around loss and grief in connection to our participants’ adoption stories. This data suggested that loss and grief may not have been processed or integrated in relation to the participants’ adoption. These findings encourage professional counselors to treat adoption status as a form of multicultural diversity and to approach counseling with adoptees with a willingness to provide ample focus on the client’s adoption story. Counselors trained in adoption issues are assets to this population, as unresolved grief can result in connection, developmental, and relational issues throughout the life span.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Marissa Meyer, MA, LPC, is Manager of Navigation at the Jefferson Center for Mental Health. Elizabeth Wiggins, PhD, LPC, LSC, is an assistant professor and the director of the Master of Arts in School Counseling program at Colorado Christian University. Gregory M. Elliott, PhD, LPC (CO), LMHC (IA), is an associate professor at Colorado Christian University. Correspondence may be addressed to Marissa Meyer, 4851 Independence St., Wheat Ridge, CO 80033, firstname.lastname@example.org.
Chad Luke, Eric T. Beeson, Raissa Miller, Thomas A. Field, Laura K. Jones
As with many advancements in science and technology, ethical standards regarding practice often follow innovation. The integration of neuroscience with counseling is no exception, as scholars are just beginning to identify important ethical concerns related to this shift in the profession. Results of an inductive thematic analysis exploring the perspectives of 312 participants regarding the ethics of integrating neuroscience with counseling are presented. This study is the first of its kind to explore mental health counselors’, counselors-in-training’s, and counselor educators’ perceptions of neuroscience integration. The researchers identified a continuum of concern ranging from no concerns to grave concerns. In addition, they identified four specific ethical quandaries: a) neuroscience does not align with our counselor identity, b) neuroscience is outside the scope of counseling practice, c) challenges with neuroscience and the nature of neuroscience research, and d) potential for harm to clients. Implications include four key considerations for counselors prior to proceeding with integrating neuroscience into practice.
Keywords: neuroscience, integration, counselor identity, ethics, counseling practice
The integration of neuroscience with the mental health professions continues, and with this expansion comes the risks associated with any nascent area of innovation (Luke et al., 2019). Neuroscience integration, as used herein, is understood using Beeson and Field’s (2017) definition of neurocounseling, a synonym for the integration of neuroscience with counseling:
A specialty within the counseling field, defined as the art and science of integrating neuroscience principles related to the nervous system and physiological processes underlying all human functioning into the practice of counseling for the purpose of enhancing clinical effectiveness in the screening and diagnosis of physiological functioning and mental disorders, treatment planning and delivery, evaluation of outcomes, and wellness promotion. (p. 74)
Counselors and the counseling profession, under code C.2.b of the American Counseling Association’s ACA Code of Ethics (2014), are charged with scrutinizing innovations and specialty areas prior to and throughout their use in clinical practice; this is a safeguard to protect clients from risky or poorly evidenced theory or practices. For example, some of these risks, as they pertain to neuroscience (i.e., the study of the brain and central nervous system) and neurobiology (i.e., literally, the biology of the neurons and the nervous system), include accuracy, embellishment, misapplication, and hype (Beeson & Field, 2017; Kim & Zalaquett, 2019; Luke, 2016).
The first and perhaps most salient ethical concern in terms of counseling values is that neuroscience integration is not a unilaterally benevolent addition to counseling (Luke, 2019). Although limited research has focused specifically on mental health counselors, several authors have closely examined the effects of using neurobiological language and frameworks to explain and understand mental health disorders in other mental health fields (Fernandez-Duque et al., 2015; Haslam & Kvaale, 2015; Lebowitz et al., 2015; Luke et al., 2019; Nowack & Radecki, 2018). Haslam and Kvaale (2015) summarized the literature on the effects of brain-based explanations of mental health conditions, such as schizophrenia and depression. Their findings challenge long-held notions that biogenic and neurobiological explanations for mental health and psychopathology are singularly positive. The larger assumption in the profession has been that biomedical explanations can reduce self-blame and public shaming of individuals with substance use and other mental health disorders (Badenoch, 2008; Lebowitz & Appelbaum, 2017). Unfortunately, these biological explanations can at times carry unintended consequences that operate against this positive outcome. Clients may be less likely to invest in psychosocial treatments, believing that while on the one hand their biogenic (i.e., brain-based) condition (e.g., depression) is not their fault, it is also therefore out of their control (Lebowitz & Appelbaum, 2017). In other words, one risk of these biological explanations is that they may reduce outcome expectancy with counseling, while increasing the belief that only biological-based treatments (e.g., psychotropic medication) will work for them.
Mental health providers also seem to be similarly affected by these biased perceptions, at times experiencing less empathy for clients in cases framed as neurobiologically based (Lebowitz & Ahn, 2014). Lebowitz et al. (2015) demonstrated that these negative effects could be mitigated somewhat through training. However, Haslam and Kvaale (2015) asserted that it is imprudent to believe that training is sufficient, because “it is unlikely that all of the ill effects of biogenetic explanation can be reversed simply by educating laypeople about bioscience, or that the fundamental problem is their ignorance of neuroplasticity and epigenesis” (p. 402). It is notable that the research above did not include mental health counselors, so the extension of these concerns to counselors remains uncertain. Nevertheless, the concerns seem warranted regarding the allure of neuroscience conceptualizations (Beeson & Miller, 2019; Field et al., 2019; Luke, 2020). Fernandez-Duque et al. (2015) demonstrated how easily humans can be deceived based on the use of the “prestige of science” hypothesis (p. 926). In a series of experiments, the authors used superfluous neuroscientific jargon and images to fool participants into viewing the content as more veracious. Additionally, concerns about the encroachment of science-based reductionism on the humanistic ethos of counseling has begun to resound through the counseling literature (Beeson, Field, et al., 2019; Beeson & Miller, 2019; Field, 2019; Luke, 2019; Luke et al., 2018). Wilkinson (2018) offered a review of the threats of neuroscience to counseling by highlighting the perceived superiority of objective brain-based methods over the humanistic principles of the counseling profession.
Nowak and Radecki (2018) introduced a special issue in the Consulting Psychology Journal: Practice and Research focused on “neuro-mythconceptions.” The authors explored the many ways that neurobiology might be exploited by professionals to justify their current practices. Their concern centered on how plausible neuroscience-based claims can sound. Such plausibility results in professionals passing along dubious information to clients in the name of cutting-edge advances in optimizing human performance. The risk of neuromyths also have been cited in the professions of counseling (Beeson, Kim, et al., 2019; Kim & Zalaquett, 2019) and education (Dekker et al., 2012; Deligiannidi & Howard-Jones, 2015; Gleichgerrcht et al., 2015; Karakus et al., 2015; Macdonald et al., 2017; Papadatou-Pastou et al., 2017; Simmonds, 2014).
Purpose of the Present Study
The potential concerns identified above highlight the need to consider potential ethical implications of counselors integrating neuroscience within their practice. Although ethical concerns regarding the implementation of neuroscience have been referenced anecdotally in conceptual reviews (e.g., Beeson & Miller, 2019; Field, 2019; Luke, 2019; Wilkinson, 2018), no studies were found that explored concerns of the counseling community regarding the broader ethical assumptions about the integration of neuroscience with practice. Therefore, this research is the first to empirically address this critical gap by eliciting the counseling community’s perceptions of ethical concerns related to the integration of neuroscience and counseling. The research question guiding this study explored if counselors perceive ethical concerns pertaining to integrating neuroscience with their counseling practice, and if so, the nature of these concerns.
This study utilized a survey-based qualitative methodology to explore counselors’ perceived ethical concerns regarding the integration of neuroscience with their counseling practice (Merriam & Tisdell, 2016). A single open-ended survey question was selected for qualitative data analysis in this study. This question was part of a larger survey examining counselor perceptions of neuroscience and neuroscience integration with counseling. Given the exploratory nature of the study and the current status of neuroscience literature in the counseling profession, a thematic analysis of a single item from a larger survey was chosen. This methodology was best suited to obtain a general, broad understanding of the concerns within the profession. Use of thematic analysis is consistent with other research in which a standardized measure of the construct (i.e., ethical integration of neuroscience with counseling) does not exist (Bengtsson et al., 2007; Donath et al., 2011). A total of 458 participants completed the larger survey, with 312 participants (67.9%) responding to the question, “What ethical concerns do you have regarding the integration of neuroscience into clinical practice (if any)?”
Integration of neuroscience with counseling practice affects multiple professional roles within the counseling profession. As such, the survey was developed for counselors, counselor educators, and counselors-in-training. We sought to gain responses from counseling practitioners, counselor educators and supervisors, and current master’s- and doctoral-level counseling students. Inclusion criteria for the study consisted of at least one of the following: (a) being licensed as a counselor, (b) belonging to a professional counseling organization, (c) being a current student in a counseling program, or (d) being a current faculty member in a counseling program. Participants who did not meet one of these four criteria were excluded from the study.
Participants varied in their educational attainment, with the highest percentage of participants having graduated with their master’s degree and not pursued doctoral study (35.3%, n = 110). This group was followed by master’s-level students (27.2%, n = 85), doctoral-level graduates (22.1%, n = 69), and doctoral-level students (15.4%, n = 48). Most of the sample (81.4%, n = 254) had attended programs accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP). Many participants (60.9%, n = 190) reported they were exposed to neuroscience in their graduate programs.
The majority of doctoral-level graduates (85.5%, n = 59) were full-time faculty members in counselor education programs. The other 10 doctoral-level graduates were either administrators of clinics, working in private practice, or retired. Of those 59 faculty members, 62.7% (n = 37) provided direct counseling services within the past year. In comparison, 81.0% (n = 205) of the non-faculty participants provided direct counseling services in the past year. When combined, the majority of the sample (77.9%, n = 243) provided direct counseling services within the past year.
The mean number of years of counseling experience was 10.13 years, with a large amount of variance (SD = 10.87). The range for years of experience was 0 to 40 years. Doctoral graduates had the most years of experience on average (M = 19.91, SD = 11.04). They were followed by master’s graduates who were not pursuing doctoral study (M = 11.70, SD = 10.42), doctoral students (M = 7.29, SD = 5.21), and current master’s students (M = 1.74, SD = 4.98). A subset of the sample comprised full-time counselor educator faculty (18.9%, n = 59). Faculty members in the study had more counseling experience (M = 17.83 years, SD = 11.00) than non-faculty participants (M = 8.33, SD = 10.04). No age differences existed by education level. The mean age for the sample was 42.55 years (SD = 13.66) with a range from 21 to 82 years.
Approximately half (54.5%, n = 170) of participants were currently licensed as counselors or psychologists. In addition, 31.1% (n = 97) held the National Certified Counselor (NCC) certification. The majority of the sample (87.5%, n = 273) were members of counseling associations. Participants self-reported their gender identity, racial/ethnic identity, age, and number of years of counseling experience. The sample consisted of 73.3% (n = 229) females, 25.0% (n = 78) males, 1.0% (n = 3) non-binary, and 0.6% (n = 2) transgender. One person did not report gender identity. The survey gave participants the option to report multiple racial/ethnic identities. Fifteen percent of participants (n = 48) identified as multiracial, whereas 84.6% identified as Caucasian/White (n = 264, of which 45 were multiracial). Of the remaining participants, 8.0% identified as Asian or Asian American (n = 25, of which 19 were multiracial), 5.4% as African American/Black (n = 17, of which 13 were multiracial), 3.8% as Hispanic or Latinx (n = 12, of which 10 were multiracial), 1.0% as American Indian or Alaskan Native (n = 3, of which three were multiracial), and 0.3% as Arab/Arab American (n = 1, of which zero were multiracial). No participants identified as Pacific Islanders.
The question addressed in this article was drawn from questions used in a larger study that explored training and attitudes related to neuroscience and counseling. The question used in this study was included intentionally as a means to gain a better understanding of perceptions of the ethics of neuroscience integration, recognizing it as a stand-alone construct for the purposes of analysis. The full survey was constructed by the authors, following a thorough review of the literature around the integration of neuroscience in counseling. All survey questions were constructed to conform to Patton’s (2015) conventions and recommendations for qualitative questions, such as using open-ended and neutral questions, asking one question at a time, and avoiding “why” questions. The specific question analyzed and presented in this report was “What ethical concerns do you have regarding the integration of neuroscience into clinical practice (if any)?”
We utilized convenience and snowball sampling to recruit participants, which makes calculating response rate difficult. However, as the purpose of the project was exploratory and the method qualitative, the participants were not intended to be fully representative. The potential response bias inherent to this study could mean that participants were aware to some degree of the status of the profession with regard to integrating neuroscience into clinical practice, both positively and negatively. Following IRB approval, the authors electronically distributed the Survey Monkey–created online survey to the following: neuroscience interest networks in counseling, the counselor education listserv, CESNET-L, and direct emails to colleagues for distribution. A link to the informed consent and full questionnaire was included in the email. Interested participants clicked on the link and were asked to give their consent in order to continue to the survey. Three separate requests for participants were disseminated, with each request coming 2 weeks apart. Participants who completed the survey in full had the option of submitting their email in a separate survey to be included in a drawing for two signed copies of neuroscience in counseling texts.
Role of the Researchers
To limit unconscious bias in the research process, we engaged in discussions throughout survey development, data collection, and data analysis. Such conversations detailed our respective passions, assumptions, histories, and visions of the profession. Several prior assumptions emerged in this recursive process. These ethical concerns largely mirrored the issues raised in existing literature and described in the introduction section of this article. The primary assumption included the belief that incorporating neuroscience into counseling is a largely positive endeavor but that counselors should follow ethical guidelines outlined by professional counseling organizations to avoid ethical concerns related to integration. One author explicitly assumed that participants would generally default to the ACA Code of Ethics in their response, such that responses might begin with, “According to the ACA Code of Ethics regarding new specialty areas of practice. . . .” One author assumed that most participants would preface their response with “It depends on what you mean by ‘integration’” because integration was intentionally undefined in the survey. We continually challenged and actively reflected on these assumptions in order to understand the impact on the authors’ relationship with the data and subsequent themes (Hays et al., 2016; Hunt, 2011). We also engaged in reflective writing, particularly through writing memos (Hunt, 2011), in order to maintain awareness of worldviews and potential for bias in coding. Commonly referred to as reflexivity, this process aided in being transparent about assumptions rather than trying to behave as if any researcher would be able to be free from biases in approaching a set of data (Hays et al., 2016). Additionally, we established an electronic audit trail that enabled returning to the data, tracking the process, and checking that the coding remained close to the words of the participants. Lastly, two of the authors served as auditors for the results, having familiarized themselves with the data, but refraining from engagement in analysis and theme development.
We selected thematic analysis, grounded in a pragmatist framework (Duffy & Chenail, 2008), to guide the inquiry into perceptions regarding the ethics of integrating neuroscience and counseling. Clarke and Braun (2017) defined thematic analysis as “a method for identifying, analyzing, and interpreting patterns of meaning (‘themes’) within qualitative data” (p. 297). We reviewed literature related to content analysis and thematic analysis and found that there was significant overlap (and sometimes merging) of the two approaches in published literature. Our best understanding of the two related approaches is that they exist on a continuum, with content analysis stopping at the manifest level of analysis and thematic analysis continuing to identify broader meanings. Although we stayed very close to the participants’ responses in coding, we did move beyond content analysis “categories” to extract some inductive-level themes across cases.
We followed Braun and Clarke’s (2006) six-phase framework, utilizing an inductive and semantic approach to thematic analysis. Braun and Clarke described these connected approaches to analysis as “a process of coding the data without trying to fit it into a preexisting coding frame, or the researcher’s analytic preconceptions . . . themes are identified within the explicit or surface meanings of the data” (pp. 83–84). Given that the data were obtained through an open-ended survey question versus an in-depth interview protocol that could capture greater context and meaning, we aimed to stay close to participants’ exact words. In this way we resisted the urge to include guesses at participants’ motivations or assumptions as part of themes. The emergent codes and themes reflect an inductive, descriptive account of participants’ perceptions. We followed the subsequent steps in analyzing the data.
The first three authors served as members of the coding team for data analysis. We first familiarized ourselves with the data by reading all responses through several times and taking notes on general observations and personal reactions to the data (Braun & Clarke, 2006). Afterward, we met via videoconferencing and looked at all the responses together, line by line, to begin identifying initial codes. The average length of responses was one to two sentences; the range of responses was from one word to over 200 words (a paragraph).
We then searched for patterns in the data, noting frequently used words and phrases and commonly expressed ideas. Fourth, we identified connections and grouped codes into preliminary themes. In doing so, we further expanded the overarching themes into subthemes, capturing some of the nuance represented in participants’ responses. We discussed and resolved differences in coding data via consensus.
Fifth, we reviewed the preliminary themes in light of the raw data and the research question, paying particular attention to our own perspectives and values. The third author re-read each participant response and matched each response to one of the theme groups. Parts of responses at times fell into different theme groups. For example, one participant wrote, “Ethical concerns would be keeping into consideration what the clinician’s scope of practice is, the potential for any side effects or results of rapid growth and brain training, and what insurance companies will cover.” The first part was coded in theme 2 (scope of practice) and the second part was coded in theme 4 (potential harm).
The first and second authors worked with the codes and themes in a more abstract and creative manner, developing thematic maps and conceptual continua that reflected relationships between and among participant responses. This process led to combining some themes and changing the title of other themes to better reflect the descriptive accounts of participants. Lastly, in refining the theme list, we discussed theme definitions and final theme names, attempting to capture the nature and essence of each thematic group (Braun & Clarke, 2006; Clarke & Braun, 2017). Clarke and Braun (2017) noted that “each theme has an ‘essence’ or core concept that underpins and unites the observations, much like characters have their own psychological makeup and motivations” (p. 108). In examining these underlying core concepts in our data, we identified questions that seemed to be illuminated through participants’ expressed concerns. As an additional step, we calculated frequency counts to convey the saturation of each theme within the data. Because the purpose of tallying frequencies was to report the strength of qualitative findings rather than to specifically quantify the results, greater weight was given to qualitative data than quantitative frequencies.
In reviewing the conceptual maps of participant responses, it appeared that participants varied in their degree of ethical concerns. To make meaning of this variation, the authors placed responses on a continuum from “none” to “yes.” These items were coded based upon whether an ethical concern was reported and under what conditions the ethical concerns existed. Some participants (4.2%, n = 13) entered “n/a,” but it could not be determined if these responses indicated whether they had any ethical concerns.
Continuum of Ethical Concerns
During the initial review of the data, the authors observed a response range that led to a further analysis of the continuum of responses. Most participants (78.2%, n = 244) indicated some level of ethical concern regarding the integration of neuroscience in counseling. These responses had various degrees of certainty and conditions. Most responses (65.1%, n = 203) fell into the yes, with no conditions grouping. Example responses included: “Deeply concerned” and “There’s a lot of misinformation out there! It’s a complex subject and I have seen varying degrees of ability to explain things easily and correctly. Also I think sometimes people want it to provide answers that it can’t or read more into the research than is truly there.”
The second category identified was yes, if/only (3.5%, n = 11). One example response included in this subtheme was: “I would only be concerned if counselors use their knowledge of the brain to profess some magical or intellectual superiority in controlling a client.” The third category was none, but (3.2%, n = 10). For example, responses included in this subtheme were: “none—except more research is needed,” and “none other than the importance of competence.”
The fourth category we identified was just like any other (3.2 %, n = 10). Some participants indicated that they had ethical concerns that were no different than for other methods of counseling. For example, one participant stated they felt “the same as with any other evidence-based practice: counselors need quality training and an understanding of what it means to be ‘competent.’” A fifth category was unethical not to integrate (3.2%, n = 10). An example response included in this subtheme was: “At this point, it would be unethical NOT to formally integrate these studies” (emphasis in original). Nearly 20% of participants (19.9%, n = 62) believed there were no ethical concerns regarding the integration of neuroscience in counseling. Given the methods of the study, the “n/a” responses were kept separate from the no ethical concerns group, as the analysis aimed to stick close to the participants’ actual words rather than infer their intention. Therefore, “n/a” could have been listed for any number of possible reasons that could not be determined in the current study. These responses were further divided into the following groups: (a) participants who believed there were explicitly no ethical concerns (13.8%, n = 43), (b) participants who believed there were no ethical concerns at the current moment (3.8%, n = 12), and (c) participants who believed there were no ethical concerns as long as certain conditions were met (2.2%, n = 7). This continuum provided a richer understanding of the emergent themes, as discussed below.
Themes of Participant Concerns
Most participants (78.2%, n = 244) identified ethical concerns. From the continuum above, these are the responses from the following groups: unethical not to integrate; no ethical concerns but; ethical concerns if/only; ethical concerns with no conditions; and ethical concerns just like any other. The analysis of these responses produced a total of four themes and ten subthemes and are summarized in Table 1. The four major themes were: neuroscience does not align with our counselor identity, neuroscience is outside the scope of counseling practice, challenges with neuroscience and the nature of neuroscience research, and potential harm to clients. For each subtheme, response frequencies are reported to provide a contextual understanding of how commonly the theme occurred. Subthemes all were deemed equally meaningful, regardless of the response frequency.
Theme 1: Neuroscience Does Not Align With Our Counselor Identity
The first theme was reflective of participants’ concerns that integrating neuroscience into counseling might be inherently inconsistent with or even violate counselors’ identity. Specifically, participants emphasized the loss of humanistic principles by either directly using the word “humanistic” or using terms consistent with humanistic principles (e.g., holism, human-first, subjective data, process, compassion, relationship, and wellness). Two subthemes related to the overarching theme were as follows: Subtheme 1.1) overemphasis and/or overreliance (n = 27), and Subtheme 1.2) reductionism and/or determinism (n = 25). These connected, yet discrete, subthemes reflected participants’ particular areas of apprehension. These areas of concern centered on either giving too much weight to biological, brain-based conceptualizations at the cost of clients’ subjective worlds (e.g., “undervalue subjective experience”) or reducing human experience in a way that neglected human agency (e.g., “reducing human experience to just science”).
Theme 2: Neuroscience Is Outside the Scope of Counseling Practice
The second theme was reflective of participants’ reservations that neuroscience was within counselors’ scope of practice based on educational backgrounds, training, knowledge, and/or skills. Three subthemes were identified as follows: Subtheme 2.1) training and education (n = 59), Subtheme 2.2) lack of standards for training and practice (n = 21), and Subtheme 2.3) competence (n = 69). Sample responses from this theme included feeling “woefully untrained.” Some participants focused more on academic background and elements of training (e.g., continuing education, supervision) as indicative of scope, whereas other participants highlighted counselors’ understanding of neuroscience concepts, focusing more on knowledge and application skills. A smaller group of responses emphasized the absence of current training and/or practice standards (e.g., “inadequate training standards”). This line of responses included concerns around an absence of qualified trainers, certification opportunities, and/or general laws and regulations.
Theme 3: Challenges With Neuroscience and the Nature of Neuroscience Research
The third theme captured participants’ varied reservations about the general field of neuroscience and the accurate translation of neuroscience research into clinical work. Participants expressing concerns in this area seemed to be asking, “How can we be sure this is done right or well?” Subtheme 3.1, ever-changing and evolving (n = 14), included responses related to challenges counselors might face in staying current with neuroscience findings. These concerns were centered around the vastness of the field and the fast pace at which research is emerging. Subtheme 3.2, quality of research (n = 23), included more critical commentary on the type of research being conducted in the neuroscience field (e.g., relevance of lab-based research to clinical practice, insufficient applied research). Subtheme 3.3, interpreting and applying research (n = 52), emphasized concerns with counselors overstating, speculating, misrepresenting, and misinforming clients of neuroscience research and concepts. Participants voiced concerns with “overhyping findings,” “unknown practical use,” and the “ever-changing and not fully understood” research base.
Theme 4: Potential for Harm to Clients
The fourth theme reflected participants’ concerns that integrating neuroscience into counseling could put clients, and potentially counselors, at risk. A total of 18 participants used the exact phrase “potential harm” or the related idea of informed consent. Fourteen participants referred to concerns with potential harm, and four people noted concerns with informed consent. In Subtheme 4.1, neuroscience information may be intentionally misused in a way that harms clients (n = 21), participants feared counselors deliberately using “embellishment” and “manipulation.” Subtheme 4.2, unintended potential negative side effects (n = 18), reflected ways that integration could inadvertently harm clients or harm counselors These concerns included giving false hope and creating problems with insurance claims to issues with liability and malpractice.
Summary and Frequencies of Themes and Subthemes
|Theme One: Neuroscience does not align with our counselor identity
||Sub 1.1 Overemphasis and/or overreliance
||The integration of neuroscience in counseling may lead to counselors giving preference to non-humanistic aspects of the client and/or the treatment process (e.g., psychopharmacology, science, the brain).
||n = 27
|• Too reliant on brain
• Science over compassion
• Defaulting to neuro
• Brain obsession
• Undervalue subjective
|Sub 1.2 Reductionism and/or determinism
||The integration of neuroscience in counseling may lead to counselors moving away from holistic conceptualizations and limiting human agency.
n = 25
• Takes away focus on
• Reducing human experience
to just science
• Cultural bias
|Theme Two: Neuroscience is outside the scope of counseling practice
||Sub 2.1 Training and education
||Counselors do not have sufficient training and/or educational backgrounds to ethically integrate neuroscience into counseling practice.
n = 59
|• Insufficient training
• Woefully undertrained
• Not having qualifications
• Scope of training
• No formal supervision
Lack of standards for training and practice
|There are insufficient standards for guiding the training and practice of neuroscience integration.
||n = 21
||• Lack of laws, regulations, and
• Standards for qualifications
• Qualifications of trainers
|Sub 2.3 Competence
||Counselors are integrating neuroscience into counseling practice without sufficient knowledge and/or skills.
||n = 69
|• Lack of knowledge
• Scope of competence
• Not being informed
• Skill level of clinician
|Theme Three: Challenges with neuroscience and the nature of neuroscience research
Ever-changing and evolving
|The field of neuroscience is continuously evolving, serving as a barrier to counselors staying sufficiently up to date to ethically integrate principles into counseling practice.
||n = 14
|• Ever-changing and not totally
• Staying current
• Constantly evolving
• Keeping up to date
• Vastness of the field
|Sub 3.2 Quality of research
||Neuroscience research is often too complex, poorly conducted, and/or insufficient for counselors to apply to their work.
||n = 23
|• More research needed
• Poor research
• Generalizability of research
• Lack of scientific foundation
• Unknown practical use
|Sub 3.3 Interpreting and applying research
||Neuroscience research is being misunderstood, misinterpreted, and/or inaccurately applied to clinical practice.
||n = 52
|• Accurately interpreting and
• Misrepresenting science
• Giving incorrect information
|Theme Four: Potential for harm to clients
||Sub 4.1 Manipulation
||Neuroscience information may be intentionally misused in a way that harms clients.
n = 21
|• Manipulation leading to
• Misuse of knowledge
• Controlling the client
|Sub 4.2 Unintended potential negative side effects
||The integration of neuroscience into counseling may have unintended negative consequences on clients and/or counselors.
||n = 18
|• Jargon alienates – feeling
• Clients misperceiving
counselor identity/role and
not attending other
Note. N = 312
Counselors, counselor educators, and counselors-in-training reported a wide range of ethical concerns regarding the integration of neuroscience with clinical practice. These concerns largely reflected existing ethical guidelines (ACA, 2014) and existing literature related to neuroscience and counseling (e.g., Beeson & Miller, 2019; Field, 2019; Luke, 2019; Wilkinson, 2018). We developed four primary themes through the data analysis process. In reviewing these themes, we identified questions that participants seem to be asking through their expressed concerns. Each of the themes shared a meaningful connection, through implication and association, with major sections of the ACA Code of Ethics (ACA, 2014). These connections are discussed below.
Theme 1: Neuroscience Does Not Align With Our Counselor Identity
Humanistic concerns in this theme reflect counselor concerns that the integration of neuroscience may shift the profession away from wellness and focus on pathology. As already noted, other scholars have shared this concern (Wilkinson, 2018). However, other authors have alluded to the possibility for neuroscience to expand rather than reduce the client experiences and actually enhance counselor identity (Beeson, Field, et al., 2019; Beeson & Miller, 2019; Field et al., 2019; Ivey & Daniels, 2016).
Humanistic concerns are consistent with criticisms in the literature regarding essentialism (Schultz, 2018). Essentialism, in particular Schultz’s neuroessentialism, is the process of reducing individuals down to mere brain function. This position reflects the positivist, materialist approach to science in general and neuroscience in particular. All human experience is based in neurobiological process (Kalat, 2019), which can feel deterministic and therefore diminish the hope that counselors are called to instill (Schwartz et al., 2016). This theme aligns with several ACA ethical codes, including counselor professional identity and values (Beeson & Miller, 2019). However, influential scholars in the counseling profession have elevated how neuroscience is an extension of the wellness perspective, akin to the professional identity of the counseling profession (Cashwell & Sweeney, 2016; Ivey et al., 2017; Russell-Chapin, 2016). Whereas this theme indicates that some counselors believe neuroscience poses ethical risks to professional identity, the reality remains unclear.
Theme Two: Neuroscience Is Outside the Scope of Counseling Practice
Concerns regarding the requisite knowledge or expertise of counselors aligns well with two specific ACA ethical code standards in this regard: C.2.a. Boundaries of Competence and C.2.b. New Specialty Areas of Practice. This theme assumes that there is a standard of competence that exists. In order for a counselor to be competent, there must be a standard to which they are compared. However, what qualifies a counselor to be competent integrating neuroscience is unclear. There are a few neuroscience-related standards outlined in the American Mental Health Counseling Association (AMHCA) Standards for the Practice of Clinical Mental Health Counseling (2020) pertinent to biological bases of behavior and CACREP practice standards (2015) pertinent to neurobiology. However, these standards are not widely known among counselors and lack recommendations for implementation (Beeson, Field, et al., 2019). This lack of explicit direction is similar to concerns regarding the implementation of other counseling standards, such as the Multicultural and Social Justice Counseling Competencies (Ratts et al., 2016).
Theme Three: Challenges With Neuroscience and the Nature of Neuroscience Research
The third theme highlighted the concern that understanding and applying the body of literature that undergirds integration are essential (Field et al., 2019; Luke, 2019). Neuroscience literature is ever-changing, ever-evolving. This rapid pace of change creates two challenges for counselors. First, counselors could have difficulty staying abreast of the state of the art of integration, leading to the potential for using outdated information in practice. Second, counselors might integrate early findings too quickly before there is enough evidence to support their integration. The quality of neuroscience-related research also appears to be a barrier to integration in that counselors may struggle to discern high-quality research from low-quality research (Gruber, 2017; Kim & Zalaquett, 2019). Related to this, counselors face the challenge of accurately interpreting and applying relevant research for practice. Results indicate a primary concern related to issues of accuracy, leading to misapplication, overstating implications, and misinforming clients. This concern is elevated by other research warning against presumed superiority in neuroscience research, given the potential for neuroscience to seduce, allure, and enchant consumers of literature (Coutinho et al., 2017; Lilienfeld, 2014; Weisberg et al., 2008). Concerns regarding the accuracy of neuroscience knowledge among counselors also have been cited (Kim & Zalaquett, 2019). However, counselors in at least one study indicated more accurate neuroscience knowledge and average endorsement of neuromyths when compared to educators, undergraduate students, and coaches (Beeson, Kim, et al., 2019).
These concerns align with several ACA ethical codes, including Section C: Professional Responsibility (2014). When counselors practice based on emergent literature with which they are only superficially familiar, they risk miscommunication with clients and damaging the veracity and integrity of the profession as it relates to client care. This finding is consistent with previous research (Bott et al., 2016; Luke, 2016) that highlights the risk of using information without great care.
Theme Four: Potential for Harm to Clients
The fourth theme has the highest salience for the profession, as safeguarding client safety and welfare are paramount (Kaplan et al., 2017). Results indicated that manipulation is a real concern among participants. Manipulation can occur through misuse, misrepresentation, embellishment, and controlling of clients through invoking neuroscience (Bott et al., 2016). Respondents reported that the actions leading to client harm may be overt. For example, in a desperate attempt to instill hope in a client, a counselor might overstate the concept of neuroplasticity. Similarly, in an effort to present as more competent than perhaps they feel, a counselor might use neuroscience-laden language with clients, resulting in alienation (Lebowitz et al., 2015). Harm may also occur through unintended consequences of integration. Clients may experience negative side effects such as false hope, deflected responsibility, and forgoing medical consultation. Similar concerns have been found in recent literature (Haslam & Kvaale, 2015; Lebowitz & Applebaum, 2017). These authors note that although on the surface integration seems positive, harm is possible. This underscores the purpose and importance of the ACA Code of Ethics regarding new specialty areas: “Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and protect others from possible harm” (ACA, 2014, C.2.b).
As with any qualitative data analysis, transferability is limited. The authors obtained the data from an online survey, using a convenience and snowball sampling method. Therefore, respondents may have had strong opinions regarding neuroscience and not necessarily be representative of the profession. Another limitation was the use of a single, open-ended question that did not allow for an in-depth follow-up. We made conservative inferences regarding the meaning and intent of the data in the discussion. However, interviews would have allowed for more context into participants’ answers. This has long been viewed as a threat to trustworthiness and transferability (Creswell & Plano-Clark, 2018). The structure of the survey in general and the question also could have influenced this result. For example, there was insufficient information available from the responses to know respondent motivation for “n/a” or “none” responses. Although it is likely that respondents did not feel they had enough information to identify ethical concerns, other reasons for such a response are also possible. White females also were overrepresented in the survey sample. This representation is consistent with surveys of CACREP-accredited graduate programs, in which White females are also overrepresented in student and faculty composition (CACREP, 2017). The findings from this study may have been different had the sample been more diverse. The voice of counselors-in-training may be overrepresented in the data. This may also reflect the increasing interest in new counselors-in-training and counselor educators–in–training of neuroscience-informed counseling (Beeson, Field, et al., 2019; Kim & Zalaquett, 2019).
Implications for Practice and Research
This research highlights the need for continued debate and evolution of who we are as counselors and what role neuroscience integration plays in our professional identity, training, and practice. Remaining silent runs the risk of counselors indiscriminately, and perhaps unethically, integrating neuroscience without adequate consideration to counselor professional identity (Luke, 2020). Forgoing these discussions also introduces the risk that counselors may not ensure that such integration enhances rather than detracts from our professional identity. Failing to do so would further support concerns described in 20/20: A Vision for the Future of Counseling (Kaplan & Gladding, 2011). The concerns highlight the consistent trend that best practices tend to be “dictated to counselors by other mental health professions” (p. 371).
A second implication is the need to clarify counselors’ scope of practice with regard to neuroscience. Only one comprehensive set of standards related to neuroscience currently exists (AMHCA, 2020). Yet even with these standards there is little awareness or training around application. Understanding scope will support preventing client harm by ensuring the previous themes are addressed. In this way, counselors will better understand the strengths and limitations of integrating neuroscience information with practice. Further, counselors should continue to practice humility regarding neuroscience evidence. In doing so, they will ensure that they also will be maintaining values (e.g., humanistic orientation) that are hallmarks of the counseling profession.
The results of this study highlight the need for more training in accessing, interpreting, and being current in neuroscience research. This focus includes the need to increase resources to support high-quality neuroscience-based studies in counseling. As scholars have asserted (e.g., Myers & Young, 2012), neuroscience provides a unique strategy to evaluate the outcomes of counseling services. The challenge, as we demonstrate in this article, is how the profession moves forward in view of these ethical standards. It is one thing to assert that counselors operate only within their scope of competence. It is another thing to articulate and circumscribe the limits of competence in an emergent area like neuroscience.
Determining ethical concerns regarding the integration of neuroscience in counseling requires several professional milestones to be met. This could begin with consensus building in the profession regarding neuroscience and counselor scope of practice. To accomplish this step, counselors need to define what it means to integrate neuroscience with practice. As noted in the current study, participants relied on their own operationalization of the integration of neuroscience. The resulting data seemed to indicate that most viewed this integration as neuroeducation (Miller, 2016) or technical applications (e.g., neurofeedback). Many have expressed more broad integration of neuroscience (e.g., Field et al., 2019) as a means to conceptualize client experiences and guide the selection and timing of various techniques.
Next, once integration is defined, there needs to be a clear standard for the training and practice of all master’s-level students (e.g., how much neuroscience does a master’s-level counselor need to know?). In addition, standards for advanced practice postgraduation also require consideration. It is unrealistic to think that master’s-level programs can prepare counselors to be experts in any area of practice, including neuroscience. As such, the profession also needs to define how much training is enough to ethically practice technology-based (e.g., neurofeedback) and non–technology-based (e.g., using to guide case conceptualization and treatment planning) integration. In doing so, counseling will create the scope of practice that can be used as a gauge of competence and limit risks to practicing outside of one’s scope.
Lastly, the counseling profession needs to develop an intentional research effort to validate training standards and therapeutic outcomes related to integration. Additional research is needed before we can appropriately discern future directions of integration. The current paucity of neuroscience literature in the counseling profession is concerning. Of particular concern is the lack of empirical and outcomes-based articles. The lack of training in how to design and evaluate research using emerging paradigms, such as the National Institutes of Health’s Research Domain Criteria, further isolates counselors from participating in national discourse regarding the future classification of mental functioning and mental health diagnoses. As the profession accomplishes these tasks, we will promote ethical care, limit the potential for harm, and ultimately advance the profession as a whole.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Chad Luke, PhD, NCC, MAC, ACS, LPC/MHSP, is an associate professor at Tennessee Tech University. Eric T. Beeson, PhD, NCC, ACS, LPC, CRC, is a core faculty member at The Family Institute at Northwestern University. Raissa Miller, PhD, LPC, is an assistant professor at Boise State University. Thomas A. Field, PhD, NCC, CCMHC, ACS, LPC, LMHC, is an assistant professor at the Boston University School of Medicine. Laura K. Jones, PhD, MS, is an assistant professor at the University of North Carolina at Asheville. Correspondence may be addressed to Chad Luke, Clinical Mental Health Counseling, Tennessee Tech University, P.O. Box 5031, Cookeville, TN 38505, email@example.com.