Nov 25, 2019 | Volume 9 - Issue 4
Alwin E. Wagener, Laura K. Jones, J. Scott Hinkle
The global burden of disease related to mental health is astronomical and growing, with underprivileged countries being disproportionately affected. The Mental Health Facilitator (MHF) program was designed by the National Board for Certified Counselors (NBCC) to address the need for greater mental health support within international communities lacking adequate mental health practitioners to provide services. The MHF program trains individuals within communities to provide support and necessary referrals for those struggling with mental health challenges. This study assesses the effectiveness of MHF trainings conducted in a diverse subset of countries and communities. Initial findings from the analyses found significant gains in participants’ knowledge of mental health and mental health facilitation skills across training populations.
Keywords: Mental Health Facilitator, MHF, mental health, NBCC, global
Over 450 million individuals around the world struggle with mental health concerns with 300 million people alone suffering from depression (World Health Organization [WHO], 2018). Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO, 2014a, para. 1). Mental disorders account for nearly 30% of the global burden of disease (i.e., what kills, injures, and disables people around the world) in terms of years lived with disability (Kessler et al., 2009; Vigo, Thornicroft, & Atun, 2016). In addition to the hardships that mental disorders place on an individual’s social relationships, occupational opportunities, and physical health, nearly 800,000 people a year die by suicide, with 75% of those individuals residing in developing countries (WHO, 2014b). Such staggering statistics include the rank of suicide as the second most common cause of death among young people globally (WHO, 2014b).
In addition to personal struggles, communities also face economic hardships related to mental disorders. The global cost of mental health was estimated at $2.5 trillion in 2010, with estimates of costs expected to reach as high as $6 trillion by 2030 (Bloom et al., 2011). Such costs can be devastating for individuals and communities alike, especially where resources are limited.
Despite the exorbitant number of individuals around the world struggling with mental health concerns and the associated individual, societal, and economic costs, only a small portion of people receive the support they need (Hinkle, 2014; Kohn, Saxena, Levav, & Saraceno, 2004; Wang et al., 2007). It is important to note that only one third to one half of individuals in high-income countries receive mental health care. This gap is even more pervasive in low- to middle-income countries, with a mere 15%–24% of individuals receiving any form of mental health support (Demyttenaere, 2004). Furthermore, according to WHO (2015), most of the world’s population live in areas where there is an average of less than one psychiatrist per 200,000 people and even fewer individuals trained in psychosocial interventions.
This gap in service provision and treatment stems from both attitudinal (e.g., misinformation about mental health such as low perceived need, stigma, and discrimination) and structural-level (e.g., availability of services, financial considerations, and transportation problems) barriers (Andrade et al., 2014; Hinkle, 2014). Although attitudinal barriers appeared to be more pervasive, overall individuals with more severe mental health conditions and those in low- or lower–middle- income countries cited financial and service availability barriers as being especially problematic. In 2011, WHO detailed the scarcity of resources available to treat and promote mental health across the spectrum of high- to low-income countries, which leads to a gap in the provision of treatment as well as the quality of treatment when it is available. For example, within high-income countries, approximately $44.84 USD is spent per person on annual mental health expenditures, a value which drops to $0.20 USD per person in low-income countries (WHO, 2011). Clearly, a strategy to lessen this gap in global mental health service provision is needed.
A Call to Action
Given the pervasiveness and deleterious consequences of mental health disorders paired with the dearth of individuals receiving treatment, there is a global imperative that countries begin prioritizing mental health awareness, education, and treatment and combatting the noted barriers to individuals seeking and receiving adequate care. Enhancing the awareness and education of not only individuals struggling with mental health difficulties, but also members of the community, would be beneficial in addressing attitudinal barriers, while providing additional resources through increasing the number of both service providers and service centers can help to eliminate structural barriers to services. Such solutions are reflected in the WHO’s (2013) Mental Health Action Plan, which outlines the following four objectives:
(1) to strengthen effective leadership and governance for mental health; (2) to provide comprehensive, integrated and responsive mental health and social care services in community-based settings; (3) to implement strategies for promotion and prevention in mental health; and (4) to strengthen information systems, evidence and research for mental health. (p. 10)
Several approaches exist to address these objectives, yet one program in particular is unique in creatively addressing multiple objectives at once. Developed by the National Board for Certified Counselors (NBCC) and initially endorsed by WHO, the Mental Health Facilitator (MHF) program aims to reduce disparities in mental health care by facilitating access to support individuals and mental health services in underserved populations (Hinkle, 2006, 2014; Hinkle & Saxena, 2006). Specifically, the MHF program trains diverse community members (i.e., mental health laypersons) in the knowledge and skills necessary to identify mental health needs, support those in need of care, work with existing care resources, and make referrals to mental health professionals as needed (Hinkle & Henderson, 2007). The program focuses on creating a culturally appropriate curriculum adaptive to community needs and contexts while also providing fundamental information concerning mental health and basic psychosocial interventions. Also, unlike many other programs, the MHF program is only tailored and implemented into specific communities at the community’s request. In this way, the MHF program content aligns with WHO’s Mental Health Action Plan by working to strengthen culturally appropriate information systems, implementing strategies for promoting mental health and decreasing the severity and pervasiveness of disorders, and enhancing responsive and integrated service provision within community-based settings tailored to the needs of that community (Hinkle, 2014).
Content of the MHF Program
The mission of the MHF program is to provide skilled, responsible access to quality mental health interventions. This is usually accomplished through basic first-contact help and referrals to mental health professionals with respect for human dignity and meeting population needs by balancing globally accepted mental health practices within local norms and conditions (Hinkle, 2014). Cross-disciplinary in nature, the MHF program includes competencies from psychiatry, psychology, social work, psychiatric nursing, and counseling, covering topics such as helping skills, diversity, violence and trauma, suicide prevention, and referral and consultation skills. The design of the training emphasizes important considerations and approaches in addressing mental health concerns while allowing for flexibility in implementation. This flexibility is a key strength of the training program and is necessary given the breadth of cultural and contextual factors affecting mental health and mental health care around the globe. Such flexibility allows local stakeholders to identify and adapt the training to local needs and the knowledge gained from the MHF training program to be implemented within existing care settings or to provide a foundation for care in areas where no established system is present. The information contained within the training and flexibility of implementation constitute a population-based mental health care approach to addressing health care needs across a broad range of social, political, economic, and cultural environments (Hinkle, 2014), and one that is growing in its evidence base.
History and Implementation of the MHF Program
The MHF program is a three-tiered, train-the-trainer implementation model that consists of MHF master trainers, MHF trainers, and mental health facilitators. MHF master trainers are selected by NBCC based on specific criteria, most notably the completion of considerable training and experience in mental health and education. MHF trainers are often professionals or paraprofessionals with mental health and teaching experience located in the community who can train community groups. MHF trainees are typically laypersons with an interest in mental health who then become the first line of support for community members with mental health needs. Following training at each of the levels, individuals are registered in the international MHF registry. Currently there are over 4,774 registered MHF master trainers, MHF trainers, and mental health facilitators located around the world.
The MHF program was first established in 2005, when NBCC worked in collaboration with WHO to establish a panel of experts, including mental health professionals from the United States, Canada, Malaysia, Trinidad, St. Lucia, Turkey, Romania, India, Mexico, Botswana, and Venezuela, who would contribute to the development of the MHF training manual, curriculum, and implementation plans. This approach led to content and delivery plans that represented diverse cultures and thus diverse perspectives on mental health, mental health care, and the role of MHF master trainers, MHF trainers, and mental health facilitators. The curriculum and master training guide were completed and piloted in Mexico City in 2007 and 2008. Later in 2008, the first train-the-trainer program was delivered in Lilongwe, Malawi. To date, NBCC has partnered with 26 countries, including eight countries in Africa, five in Asia, four in the Middle East, and eight in Europe, as well as programs in Mexico and the United States. Furthermore, the MHF curriculum has been translated into Arabic, Chinese, Dzongkha (the language of Bhutan), Estonian, German, Greek, Japanese, Malay, Portuguese, Romanian, Russian, Spanish, and Swahili (Hinkle, 2014).
The MHF Curriculum
When developing a partnership with NBCC, communities can choose one of five MHF curricula to best suit their needs, namely the original MHF training, an abridged MHF training, a training for educators (MHF-EE), an abridged MHF-EE, or a version for first responders (i.e., fire, rescue, and police). The five MHF curricula share core content aimed at helping professionals and paraprofessionals improve communication and helping skills, identify local mental health resources, understand important ethical considerations, and connect health providers with individuals within their community who are in need of mental health services (Hinkle, 2014). In addition to the core content, the curricula directed toward educators and emergency personnel contain tailored modules to best support those populations. With trainings ranging from 6 to 30 hours, the curricula can be delivered over consecutive days or divided into its modules and taught over several weeks, depending on community needs (Hinkle & Henderson, 2007).
The foundation of the MHF curriculum underscores the shared experiences of stress, distress, and disorder (Desjarlais, Eisenberg, Good, & Kleinman, 1995; Hinkle, 2014; Hinkle & Henderson, 2007). Given these theoretical underpinnings, the core modules cover topics such as basic helping skills, coping with stress, community mental health services, and community advocacy skills, and also introduce trainees to considerations around ethical practice and specifics about interventions such as suicide mitigation and trauma responses (Hinkle, 2014). Participants learn the benefits of investing in mental health, barriers to mental health care, cost-effective interventions, how mental health disorders impact families, confidentiality and privacy, and the broad mission of the MHF program (Hinkle, 2014).
In the basic helping skills section of the training, trainees cover development; diversity; verbal and nonverbal communication; facilitative skills such as listening, asking questions, and providing reflections; assessing for mental health concerns; empathy and understanding human feelings; and how to make referrals and effectively terminate relationships (Hinkle, 2014; Hinkle & Henderson, 2007). This information is followed by a discussion of how to understand problems, coping styles, and ways of effectively managing problems. The training then delves into recognizing stress, distress, and various disorders, including risk factors and mental health in children. The core modules conclude with discussions of suicide and trauma. Being the leading cause of death among young people in low- and middle-income countries, suicide is a pressing concern within all communities (WHO, 2006). Similarly, the pervasiveness of natural and human-born disasters and crises, such as war, forced displacement, human trafficking, typhoons, and wildfires, affects individuals of all demographics around the world and often goes untreated (Hinkle, 2014). A final topic covered in the core MHF training is the importance of self-awareness and self-care for mental health facilitators.
Moreover, the content in any of the five MHF curricula can be adapted to best fit the social, cultural, economic, and political realities and needs of any community, country, or region. For example, countries have chosen to add additional modules on child maltreatment in the Syrian region.
Past and Ongoing MHF Research
Building a strong evidence base is imperative to the development of a sustainable program that addresses the staggering gap that exists in mental health service provision. With limited resources spent on mental health, countries and communities cannot afford to implement programs that lack evidence supporting their projected outcomes and benefits. To this end, NBCC has and will continue to emphasize building a solid evidence base for the MHF program. Qualitative studies published to date (Luke, Hinkle, Schweiger, & Henderson, 2016; Van Leeuwen, Adkins, Mirassou-Wolf, Schweiger, & Grundy, 2016) support the perceived value and effectiveness of the program. Luke et al. (2016) reported that among the value and benefits, participants commented on how the program was culturally congruent and beneficially adapted to the needs of their community as well as how the program filled a need in terms of limited mental health resources. Participants further noted the considerable negative implications if the MHF program were to be discontinued (Luke et al., 2016). Van Leeuwen et al. (2016) also found notable positive perceptions of the MHF program. Participants reported that they gained skills in communication and referral. They also noted how they received important education on mental health and causes of mental health problems, and an enhanced awareness of mental health in communication. Finally, participants reported that there were both personal and community benefits to the program, such as an ability to better understand their own mental health and the mental health of family members as well as a reduction in community mental health stigma (Van Leeuwen et al., 2016).
However, to date no study has reported the quantitative outcomes of MHF trainings. Most trainings include pre- and post-training assessments of participants using a true-false, pencil-and-paper–based assessment. The assessment for the original MHF curriculum had three small adaptations involving changing the wording on several questions in 2009, 2011, and 2013. The adaptations were minimal, so all years were included in this study. This study fills the gap in the MHF literature by reporting on the objective data gathered from the pre- and post-training assessments of the original MHF curriculum.
Methods
This study uses a quasi-experimental research design to evaluate whether participants in 88 MHF original trainings demonstrated increased knowledge of mental health issues and approaches to address community mental health concerns. The trainings spanned from 2009–2017 and included all MHF trainings conducted outside of the European Union and the United States. For each MHF training, pre- and post-training assessments were completed by all participants in an effort to evaluate the effectiveness of training. The pre- and post-training assessments contained 50 true-false questions with the pretest administered on the first day of training and the posttest administered at the final training day, 5 days later. The present study analyzed the pretest and posttest evaluations using paired t-tests and a one-way ANOVA.
Participants
Participants who completed all items on both the pretests and posttests were included in the study, resulting in 1,392 participants from 15 countries. Of the 1,392 participants, only 735 provided descriptive information. For those participants, 431 were female (59%) and 304 were male (41%). The age range of participants was 17 to 75 years with a mean age of 36 years. The education of participants ranged from elementary school to doctoral (PhD) and professional degrees (MD and JD). There were 14 participants reporting only an elementary school level of education (2%), 150 with high school (20%), 151 with a 2-year degree (21%), 310 with a 4-year degree (42%), 99 with a master’s degree (13%), and 11 with a PhD or professional degree (1%). Given that trainings were conducted in countries within North America, Africa, Asia, and the Middle East, the data included a diverse range of participants in terms of nationality.
Research Questions
There were two primary questions investigated in this study. The questions were prompted by a desire to better understand the effectiveness of the MHF trainings: (1) Does the MHF program training significantly increase overall knowledge of mental health facilitation from pretest to posttest evaluation for participants? and (2) How does performance on the pretest, or initial mental health knowledge, affect possible training gains made between pretest and posttest scores for the participants?
Data Preparation
Prior to formal data analyses, the authors examined the data to ensure it satisfied the assumptions of the relevant statistical tests. Upon initial data examination, the authors determined that 77 participants of an initial 1,392 were outliers. The outliers were those with scores 1.5 times the interquartile range, either above the third quartile or below the first quartile. Based on this, the data analyses presented in the following sections were run with and without the outliers removed, and it was determined that the outliers did not significantly affect the results (the only exception to the outliers affecting the results is described in the results section). As such, the data analyses presented are using the remaining 1,315 participants after the removal of the outliers.
As the data set is too large for statistical normality tests to be accurate, skewness and kurtosis values were examined. The data set without the outliers had skewness (.208) and kurtosis (-.018), both values within the normal range. A visual inspection of the descriptive q-q line further supported the conclusion that the data is normally distributed.
Results
Overall Mental Health Knowledge Gain
The first research question, asking whether the MHF program training significantly increased overall knowledge of mental health and mental health facilitation, was assessed using a paired sample t-test. The result of this analysis showed that there was a significant difference (t = -35.90, p = 0.000) between pretest (M = 37.64, SD = 5.58) and posttest (M = 41.17, SD = 5.24) scores. This analysis confirms the hypothesis that the MHF program training significantly increases the scores of participants from pretest to posttest evaluation.
Initial Mental Health Knowledge and Training Gains
The second research question investigated whether the starting knowledge of participants, as measured in the pretest, affected the training gains made between the pretest and posttest. To address this research question, four categories based on pretest scores were generated. A descriptive analysis was conducted to determine the quartiles of the pretest scores, and the quartiles were used to define the categories. The authors determined that quartiles are an effective means of dividing the pretest scores into four groups given that the relationships between the groups are clearly linked to the overall distribution of pretest scores. The pretest scores ranged from 15–50 (the range of possible scores was 0–50), and quartiles were generated in order to better understand the effects of MHF training on participants with low, medium-low, medium-high, and high MHF knowledge going into the training. The quartile scores were as follows: low < 34 (N = 317, M = 5.34, SD = 4.23), medium-low = 34 to 38 (N = 369, M = 4.13, SD = 3.62), medium-high = 39 to 42 (N = 340, M = 3.06, SD = 2.69), and high > 42 (N = 289, M = 1.35, SD = 2.04).
To compare the four groups and answer the second research question, a one-way ANOVA was used. The analysis showed that the differences between the scores of the four categories are significant (F[3, 1311] = 81.05, p = 0.000). A post-hoc Tukey HSD test allowed for a more detailed understanding of the difference between the four groups. The Tukey HSD test results indicated significant differences between all four groups. The details of the differences between means in the post-hoc test are as follows. The low score group showed a significant difference between pretest and posttest scores compared to the medium-low test score group (mean difference = 1.21, p = 0.000), the medium-high test score group (mean difference = 2.28, p = 0.000), and the high test score group (mean difference = 3.99, p = 0.00). The medium-low test score group was significantly different from the medium-high (mean difference = 1.07, p = 0.000) and high (mean difference = 2.78, p = 0.000) test score groups, and the medium-high test score group was significantly different from the high test group (mean difference = 1.71, p = 0.000). When running the one-way ANOVA with the outliers included, the only difference in significance found in the results for any of the analyses occurred between the medium-low and medium-high groups. With the outliers included in the analysis, there was no significant difference between those two groups, although all the other significant differences remained, and the overall trend of pretest to posttest score differences decreasing as the pretest score rose remained unchanged. The results of the analyses confirm that the lower the pretest scores, the larger the gain in knowledge from the training.
Post-Hoc Data Analysis
After considering the significant pretest to posttest gains, the authors became curious about whether the content of the pretest and posttest questions might be separated into subscales to better evaluate MHF training effectiveness. The observation that the questions on the MHF pretests and posttests naturally related to either knowledge or skills prompted the authors to separate the questions into the two subscale categories, MHF knowledge and MHF skills.
To generate the two subscales, one author went through the questions independently and categorized them for each of the three test iterations. Then, the second author went through the questions to confirm they fit the subscales. A paired t-test was used to determine whether participants demonstrated equivalent gains in both knowledge and skills.
The results of the analyses showed significant gains on both subscales. The mean gain on MHF knowledge was 1.41 (N = 1315, t = -22.86, p = 0.000), and the mean gain on MHF skills was 2.12 (N = 1315, t = -29.67, p = 0.000). The results of this post-hoc analysis confirm the hypothesis that the MHF program training leads to significant increases in both MHF knowledge and skills.
Discussion
The results of the present study provide further evidence of the effectiveness of the MHF program. Previous studies have examined qualitative accounts of trainees’ experiences and impressions of the program (Luke et al., 2016; Van Leeuwen et al., 2016). The present data, however, provide objective evidence that the program is indeed enhancing trainee knowledge of mental health and MHF skills. This finding suggests that individuals who complete the MHF program have the requisite knowledge and skills to provide frontline interventions and needed referrals for community members struggling with their mental health.
Interestingly, the results also demonstrate that the documented growth in knowledge and skills is relative to the existing knowledge of the participant prior to training, whereby those with less initial training (i.e., lower scores on the pretest) showed greater gains in knowledge and skill from participation in the MHF training. Although somewhat intuitive, this provides evidence that the program is successful at enhancing the knowledge and skills of participants despite previous training in mental health. It brings all participants up to a similar, requisite baseline level of knowledge to perform mental health facilitation. Participants with little to no information regarding mental health can gain the needed knowledge and skills necessary to support the mental health of others in their community, while those with considerable information and training can refine their skills and knowledge for their new role.
Post-hoc analyses assessed whether the MHF program is equally adept at enhancing knowledge related to mental health and mental health struggles as well as the skills needed in mental health facilitation. Findings revealed that participants demonstrated a significant growth in both knowledge and skills. As such, the MHF program not only provides mental health literacy, but also the skills needed to support those in need. This is notable given the significant disparity of mental health literacy in both the developed and developing world (Ganasen et al., 2008; Jorm, 2000). Among professionals and laypersons alike, the lack of knowledge and understanding of mental health not only contributes to the treatment gap, but also the considerable stigma faced by those who struggle with mental health issues.
Taken together, the results suggest that the researchers and program developers can confidently endorse this program as one that leads to an increase in mental health knowledge and skills associated with mental health facilitation among both professionals and laypersons. In this way, the MHF program furthers the WHO’s (2013) Mental Health Action Plan goals of strengthening information systems surrounding mental health and clearly establishing a requisite foundation for the implementation of strategies and services. In its proposed actions for member states, WHO emphasized the importance of human resource development by “build[ing] the knowledge and skills of general and specialized health workers to deliver evidence-based, culturally appropriate and human rights-oriented mental health and social care services” (WHO, 2013, p. 15).
Our findings also complement the positive evaluation feedback of participants. In particular, Van Leeuwen et al. (2016) found that participants appreciated the increased knowledge they gained, noting that it was beneficial to themselves as well as their community. Participants noted that they had an enhanced ability to better understand their personal and family members’ mental health and that the MHF training helped reduce community stigma. Examined in conjunction with the present data, this suggests that not only are participants objectively gaining knowledge about mental health, they are aware of what they learned and actively and intentionally applying that knowledge to help themselves, other individuals, and their overall community better understand mental health. Given that the present study also demonstrated that participants are gaining an enhanced understanding of MHF-related skills, the researchers are hopeful that with their knowledge of mental health, participants are likewise intentionally putting their facilitation skills into action to support those in need within their communities.
Limitations and Future Research
The present study provides a notable step in further documenting the effectiveness of the MHF program, yet the limitations of this research must be taken into consideration and used for ongoing program planning and research development. Using true-false repeated measures pre- and post-training assessment could lend itself to bias. Within such situations, the trainee may recall, implicitly or explicitly, the questions asked in the pre-training assessment and may be primed for remembering the information needed to respond to those questions. Similarly, although the findings were statistically significant, probability suggests that true-false questions are more accessible to educated guesses rather than a depiction of accurate knowledge. In this way, having a multiple-choice format test with possible case scenarios to assess application in greater depth might provide a richer depiction of the knowledge gained. The present means of assessment also are vulnerable to a ceiling effect, whereby those with the most knowledge around mental health would earn the maximum number of points on both the pre- and post-training assessment. Although the present testing level is the most adaptive to all knowledge levels, perhaps a greater breadth of questioning to assess more nuanced components of the MHF skillset might be more helpful in accurately assessing the knowledge and skills gained by those coming into the MHF program with more extensive mental health training. An additional limitation of the assessments specifically was the post-hoc distinction between the skills and knowledge components assessed in the MHF training. In the future, greater attention to developing questions specifically geared toward these two necessary areas will be more effective in discriminating such gains. One final limitation of the present study and an area well positioned for future research is the lack of specific data regarding how the knowledge and skills are being used following the training.
Prior to this study, there was no formal quantitative data analysis to substantiate the reach of the MHF program. In addition to this research assessing the knowledge and skills gained through participation in the MHF program, there is the equally important next step of assessing how that knowledge is being used to address the goals of the program. Research examining the extent to which the MHF program aides in increasing mental health access for individuals in need of support and thereby decreasing the treatment gap among individuals struggling with their mental health would be especially important in addressing the over 70% of individuals in developing countries who do not receive the mental health care they so desperately need (Demyttenaere, 2004).
Conclusion
The growing number of individuals around the world with mental health challenges, coupled with the lack of knowledge, services, access, and fiscal resources to address the growing need, drives mental health to the forefront of worldwide public health challenges. Countries and communities in both developed and developing countries alike must embrace creative, economical, and culturally appropriate population-based solutions. The MHF program developed by NBCC (Hinkle & Henderson, 2007), initially in coordination with WHO and mental health experts from around the world, provides one such solution. Extant research on the MHF program validates the cultural appropriateness of the tailored programs as well as the extent to which community members believe they have benefited from the trainings (Luke et al., 2016; Van Leeuwen et al., 2016). The present findings further this research by providing quantitative data speaking to the effectiveness of the program at enriching participants’ knowledge and skills in relation to mental health. This burgeoning evidence base moves the MHF program one step closer to becoming a global best practice in addressing the notable and growing gap in mental health care around the world.
Conflict of Interest and Funding Disclosure
The first two authors were reimbursed by NBCC
for expenses related to this manuscript.
The third author is an employee of NBCC who
has developed and conducted MHF trainings.
References
Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A., Borges, G., . . . Kessler, R. C. (2014). Barriers to mental health treatment: Results from the WHO World Mental Health surveys. Psychological Medicine, 44, 1303–1317. doi:10.1017/S0033291713001943
Bloom, D. E., Cafiero, E. T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L. R., Fathima, S., . . . Weinstein, C. (2011). The global economic burden of non-communicable diseases. Geneva, Switzerland: World Economic Forum.
Demyttenaere, K., Bruffaertts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J. P., . . . Chatterji, S. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health surveys. JAMA, 291, 2581–2590. doi:10.1001/jama.291.21.2581
Desjarlais, R., Eisenberg, L., Good, B., & Kleinman, A. (1995). World mental health: Problems and priorities in low-income countries. Oxford, England: Oxford University Press.
Ganasen, K. A., Parker, S., Hugo, C. J., Stein, D. J., Emsley, R. A., & Seedat, S. (2008). Mental health literacy: Focus on developing countries. African Journal of Psychiatry, 11, 23–28. doi:10.4314/ajpsy.v11i1.30251
Hinkle, J. S. (2006, October). MHF town meeting: Ideas/questions. Presentation at the NBCC Global Mental Health Conference: Focus on the Never Served, New Delhi, India.
Hinkle, J. S. (2014). Population-based mental health facilitation (MHF): A grassroots strategy that works. The Professional Counselor, 4, 1–18. doi:10.15241/jsh.4.1.1
Hinkle, J. S., & Henderson, D. (2007). Mental health facilitation: Program history and summary. Greensboro, NC: National Board for Certified Counselors. Retrieved from http://mentalhealthfacilitator.com/Assets/Project_Summary.pdf
Hinkle, J. S., & Saxena, S. (2006, October). ATLAS: Mapping international mental health care. Presentation at the NBCC Global Mental Health Conference: Focus on the Never Served, New Delhi, India.
Jorm, A. F. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders. The British Journal of Psychiatry, 177, 396–401. doi:10.1192/bjp.177.5.396
Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., . . . Wang, P. S. (2009). The global burden of mental disorders: An update from the WHO World Mental Health (WMH) surveys. Epidemiology and Psychiatric Sciences, 18, 23–33. doi:10.1017/S1121189X00001421
Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004). The treatment gap in mental health care. Bulletin of the World Health Organization, 82, 858–866. doi:10.1590/S0042-96862004001100011
Luke, M., Hinkle, J. S., Schweiger, W., & Henderson, D. (2016). Mental health facilitator (MHF) service implementation in schools in Malawi, Africa: A strategy for increasing community human resources. The Professional Counselor, 6, 1–21. doi:10.15241/ml.6.1.1
Van Leeuwen, J. M., Adkins, S., Mirassou-Wolf, T., Schweiger, W. K., & Grundy, R. (2016). An evaluation of the Mental Health Facilitator programme in rural Uganda: Successes and recommendations for future implementation. Journal of Psychology in Africa, 26, 288–299. doi:10.1080/14330237.2016.1185919
Vigo, D., Thornicroft, G., & Atun, R. (2016). Estimating the true global burden of mental illness. The Lancet Psychiatry, 3, 171–178. doi:10.1016/S2215-0366(15)00505-2
Wang, P. S., Angermeyer, M., Borges, G., Bruffaerts, R., Chiu, W. T., De Girolamo, G., . . . Usten, T. B. (2007). Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry, 6, 177–185.
World Health Organization. (2006). Integrating mental health into primary care: A global perspective. Geneva, Switzerland. Retrieved from https://www.who.int/mental_health/resources/mentalhealth_
PHC_2008.pdf
World Health Organization. (2011). Mental health atlas 2011. Retrieved from https://apps.who.int/iris/
bitstream/handle/10665/44697/9799241564359_eng.pdf;jsessionid=7488A5219E439A1D1D082CCFA2E872E5?sequence=1
World Health Organization. (2013). Mental health action plan 2013–2020. Retrieved from http://www.who.int/mental_health/publications/action_plan/en/
World Health Organization. (2014a). Mental health: A state of well-being. Retrieved from http://www.who.int/features/factfiles/mental_health/en/
World Health Organization. (2014b). 10 facts on mental health. Retrieved from https://www.who.int/features/factfiles/mental_health/mental_health_facts/en/
World Health Organization. (2015). Mental health atlas 2014. Retrieved from http://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2014/en/
World Health Organization. (2018). Mental disorders. Retrieved from
http://www.who.int/mediacentre/factsheets/fs396/en/
Alwin E. Wagener, NCC, is an assistant professor at Fairleigh Dickinson University. Laura K. Jones is an assistant professor at the University of North Carolina Asheville. J. Scott Hinkle is the editor of The Professional Counselor. Correspondence can be addressed to Alwin Wagener, 285 Madison Ave., M-AB2-01, Madison, NJ 07940, awagener@fdu.edu.
Nov 11, 2019 | Volume 9 - Issue 4
Allison Crowe, Paige Averett, Janeé R. Avent Harris, Loni Crumb, Kerry Littlewood
The following study assessed the utility of the U. S. Department of Health and Human Services’ definition of mental health among participants in the rural Southeastern United States. Using deductive coding, qualitative results revealed that participants do not conceptualize mental health in comprehensive terms. Rather, they tend to describe mental health with a focus on cognition. The sample articulated “well-being” to describe mental health; however, they most often connected it to cognition. The findings suggest that rural communities could benefit from mental health education with a holistic approach and that the use of the term well-being provides a pathway for clinical connections. Future research should consider interviewing rural participants to gather more detail on their definitions and understanding of mental health.
Keywords: mental health, education, cognition, rural, well-being
Mental illness is a pervasive health care concern in the United States. Even though approximately one fifth of adults experience mental health concerns in any year, only 70% of those in need of mental health services seek care (National Alliance on Mental Illness, 2015). Because of how common and widespread mental health conditions are in the United States, mental health professionals have become increasingly aware that educating the public about mental illness is of utmost importance. Mental health literacy (MHL; Jorm, 2012), or the knowledge and beliefs about disorders that assist in the recognition, prevention, or management of a mental health concern, is one way those who are struggling with mental health concerns can manage mental illnesses more effectively. Improving MHL can have the capacity to positively impact negative attitudes, biases, or assumptions that are associated with having a mental illness as well as assist with help-seeking so those who have a mental illness will receive necessary treatment (Crowe, Mullen, & Littlewood, 2018; Jorm, 2012; Kutcher, Wei, & Coniglio, 2016). Researchers have consistently demonstrated that a stigma still exists toward seeking help for mental health concerns and that reducing that stigma is of utmost importance (Kalkbrenner & Neukrug, 2018).
Increasing help-seeking behaviors might best be done through first exploring attitudes and perceptions, as cognitions are closely tied to emotions and behaviors. Therefore, the current study is framed through the theoretical lens of cognitive behavioral therapy (CBT; A. T. Beck, 1970). CBT is based on the notion that how one thinks, feels, and acts are all intertwined. Specifically, one’s thoughts impact how one feels and behaves. Because of this, negative or unrealistic thoughts may contribute to psychological distress. When a person feels distressed, the way that they interpret situations may become skewed or distorted, which then impacts their behavior. From the lens of CBT, one’s decision to not seek treatment for a mental health concern may be closely tied to the thoughts and feelings they hold about negative associations about mental illness. Counselors who practice from a CBT perspective work with clients to identify and eliminate cognitive distortions in order to minimize painful emotions and promote more adaptive behaviors. CBT has been applied to diverse populations and found to be effective with various presenting concerns (A. T. Beck, 1970; J. S. Beck, 2011; Crumb & Haskins, 2017).
Cognitive distortions exist as they relate to having a mental health concern, and researchers have shown that rural residents with mental health concerns fear being negatively labeled, stereotyped, and discriminated against and thus are apprehensive to seek mental health care services (Crumb, Mingo, & Crowe, 2019). Therefore, it is vital that counselors and other mental health providers consider how clients’ thoughts, beliefs, experiences, and other contextual factors contribute to their understanding of mental illness. Intentional acknowledgment of the factors that influence clients’ perceptions, attitudes, and behavior may enhance treatment efficacy for rural residents (Crumb & Haskins, 2017). Along with exploring negative thoughts related to mental health, researchers also have considered MHL, or one’s understanding of mental health, as it impacts behaviors.
Mental Health Literacy (MHL)
Health literacy researchers suggest low health literacy is related to a number of negative health outcomes, including higher instances of chronic illness, lower usage of health care programs, higher costs of health care, and premature death (Baker et al., 2007; Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011). The World Health Organization (WHO; 2013) posits that health literacy is more important than demographic factors (e.g., income, employment, status, education, race, ethnicity) as they relate to health status. Perhaps because of this, the importance of health literacy is well established in the health professions.
In a 2011 literature review on health literacy outcomes, Berkman and colleagues found that lower levels of health literacy were related to more hospitalizations, increased emergency center use, misuse of medications, confusion with medication instructions, higher death rates, and poorer overall health among the elderly. Baker and colleagues (2007) had similar findings related to the impact of poor health literacy on health outcomes. In Baker et al.’s cohort study (N = 3,260), inadequate health literacy independently predicted mortality and death because of cardiovascular disease in elderly populations. They concluded that health literacy is an influential component of overall health.
Compared to general health literacy, the same cannot be said specifically for MHL in the field of mental health. In fact, knowledge of mental health concerns is greatly lacking and largely ignored (Jorm, 2012). The most current study related to MHL found that MHL had a negative relationship to self-stigma of mental health concerns and help-seeking, signifying that when a person knows more information about mental health, they have less stigma about mental health concerns and engage in more help-seeking behaviors (Crowe et al., 2018). In this same study, health outcomes (i.e., blood pressure and body mass index) were assessed to test whether MHL was related to improved physical health. Results were nonsignificant, suggesting that there was not a relationship between MHL and physical health outcomes.
Regional disparities and sociodemographic variations in treatment utilization and efficacy reflect a crucial need for increasing MHL in rural areas in particular (Smalley, Warren, & Rainer, 2012; Snell-Rood et al., 2017). Although prevalence rates of mental health concerns are similar to urban and suburban regions, the amount of and access to mental health services differ vastly in rural regions. Rural residents have fewer options for services, and in fact many rural areas have no health care services at all (Rural Health Information Hub, 2017). Residents in rural regions must travel greater distances for mental health services, are less likely to have health insurance, and have lower MHL (Rural Health Information Hub, 2017). Therefore, professional literature and research studies that assist with raising knowledge about MHL are warranted, as the current literature based on this topic is lacking, especially as it relates to types of settings and samples of the population. Thus, the current study was an attempt to address this gap in the literature. The following section focuses on what is known about mental health in rural areas and highlights the salient issues that are of importance to clinicians and researchers alike.
Mental Health in Rural Areas
The mental health of rural residents is of importance, as 16% of the U.S. population lives in rural areas (Rainer, 2012). Of those living in the rural United States, 90 million residents live in areas that have been designated as Mental Health Professional Shortage Areas and are lacking mental health professionals and resources (Health Resources & Services Administration, 2011). Researchers, practitioners, and recipients of mental health services purport the underutilization of mental health services and inadequacies in the quality of mental health care among rural populations (Smalley et al., 2012; Snell-Rood et al., 2017). Specifically, factors related to acceptability, accessibility, and availability intensify rural mental health disparities across the United States (Office of Rural Health Policy, 2005; Smalley et al., 2012).
A study completed in Australia sought to explore perceptions about mental health in a rural sample (Fuller, Edwards, Procter, & Moss, 2000). Themes revealed a reluctance to acknowledge mental health concerns and seek help from a professional. Results also demonstrated there is a mental health stigma that is particular to rural communities. Although the study provided an initial look at how mental health can be understood in rural areas, the sample consisted of mental health professionals and others who were knowledgeable about mental health issues rather than those from the general client population.
Mental health stigma is one of the most common reasons for unmet mental health needs in rural areas (Alang, 2015; Stewart, Jameson, & Curtin, 2015). For example, residents in rural communities report fear of taking psychotropic medications and that seeking treatment for mental health might adversely impact their employment (Snell-Rood et al., 2017; Stewart et al., 2015). Resultantly, rural clients who experience mental illness enter mental health care later, present with more serious symptoms, and often require more intensive treatment (Smalley et al., 2012). Insufficient MHL, such as misinformation related to common mental health disorders and treatment, can lead to lower rates of recognizing symptoms of depression, anxiety, and an array of other mental health concerns among rural residents in various ethnic and age groups (Kim, Saw, & Zane, 2015).
A quantitative study conducted by Alang (2015) investigating the sociodemographic disparities of unmet health care needs revealed men in rural areas were more likely to forgo mental health care because of gender stereotypes about mental health problems that encourage men to ignore mental health concerns and avoid help-seeking behaviors. Similarly, Snell-Rood et al. (2017) found that rural women face issues with mental health treatment quality and stigma related to specific disorders such as depression as well as a cultural expectancy of self-reliance, which impacts treatment efficacy. Study participants shared that the quality of counseling in their rural settings was unsatisfactory because of counselors recommending coping strategies that were “inconsistent” with their daily routines and beliefs, not offering adequate “direction” on how to approach treatment for their concerns, and having a lack of therapeutic interaction (Snell-Rood et al., 2017). Because of negative perceptions of the quality of mental health treatment, many women in the study were ambivalent in regard to seeking professional help. Rather, they relied on their personal approaches to symptom management (e.g., avoidance, reflection, and prayer).
Accessibility of mental health services is a significant concern in rural areas. Rural residents face challenges in finding transportation to facilities for professional care. Consequently, rural residents often forgo attaining adequate and timely mental health treatment (Alang, 2015; Hastings & Cohn, 2013). Rural residents often depend on alternative sources such as faith-based organizations to address mental health concerns (Bryant, Moore, Willis, & Hadden, 2015) or ignore the prevalence of mental health symptomology altogether (Snell-Rood et al., 2017). Unfortunately, researchers indicated that rural residents seek treatment for mental health disorders after they have become progressively worse, resulting in more extensive treatment, which is often unavailable or costly for rural clients (Gore, Sheppard, Waters, Jackson, & Brubaker, 2016; Hastings & Cohn, 2013; Snell-Rood et al., 2017). Deen and Bridges (2011) suggested these delays in seeking mental health treatment are associated with low MHL.
Treatment availability for mental health care in rural areas is fragmented because of critical shortages in mental health care providers in these communities (El-Amin, Anderson, Leider, Satorius, & Knudson, 2018; Snell-Rood et al., 2017). Practitioner shortage is attributed to difficulty in recruiting and retaining professionals for rural practice as well as practitioners’ limited understanding of cultural norms and effective interventions to address mental health needs in rural communities (Fifield & Oliver, 2016; Hastings & Cohn, 2013). Among practitioners who provide clinical services in rural areas, many report feeling incompetent to work with the population because of receiving fewer training opportunities to learn how to work with rural populations, less access to consultation resources, and professional isolation (Hastings & Cohn, 2013; Jameson & Blank, 2007). Fifield and Oliver (2016) found the most common need of rural-area mental health professionals was training opportunities specific to rural mental health counseling. Pointedly, rural mental health service providers are encouraged to tailor interventions and informational material to meet the needs of the specific communities in which they practice (Crumb, Haskins, & Brown, 2019; El-Amin et al., 2018). For example, a qualitative study examining the experience of rural mental health counselors found it was necessary for rural counselors to modify their interventions to include community-based interventions and expand their roles to include consulting, advocacy, and case management to effectively meet the needs of rural clientele (Crumb, Mingo, & Crowe, 2019). In 2012, rural-specific supplemental materials and curricula were integrated into the standard Mental Health First Aid program, a training course disseminated by the National Council for Behavioral Health to address gaps in MHL by teaching skills to help individuals identify, understand, and respond to mental illness (El-Amin et al., 2018; National Council for Behavioral Health, 2019). Based upon extant research evidence, cultural distinctions in rural living impact MHL and, subsequently, the quality of mental health care in rural regions of the United States.
Despite the above-mentioned disparities, there are opportunities for improving the mental health care of those in underserved rural areas. By becoming familiar with how rural residents in the United States define mental health and investigating the sociodemographic idiosyncrasies in the meaning of mental health for rural residents in specific regions of the United States, mental health practitioners can understand how to better address needs, counter structural barriers to treatment, and improve overall mental health care in rural areas. As far as we are aware, there are no studies that have examined how those in rural communities define and conceptualize mental health. Thus, the current study was designed to fill this gap in the literature.
This study sought to understand how individuals in the rural Southeast define and conceptualize mental health in order to explore MHL and serve as a guidepost to providing culturally relevant services to residents in these regions. Areas in the Southern United States have a high concentration of rural residents who potentially have less access to mental health services, which may influence their overall MHL (El-Amin et al., 2018). Furthermore, we know little about how rural populations define mental health and the knowledge and beliefs that undergird their understanding of mental health. Rather, we have definitions of mental health that are taken from large national and international entities (e.g., U.S. Department of Health and Human Services, Centers for Disease Control and Prevention [CDC], WHO) that offer broad ways of understanding the term. These definitions, although useful, may not capture distinctions associated with region, socioeconomic status, or cultural group differences. Understanding how groups of people view mental health has many benefits to enhancing MHL. A more specific understanding of mental health concepts can serve as a foundation to increase the utilization of mental health services, improve the quality of care, and enhance clients’ ability to communicate concerns. If there are to be greater gains in prevention, intervention, and management of mental health in rural, southern regions of the United States, we need a comprehensive understanding of aspects that are included in perceptions of mental health—using their own words.
Methods
Procedures
Prior to data collection, the Institutional Review Board at a Southeastern U.S. university granted approval to complete the study to explore MHL. Data were collected via a paper-and-pencil survey. Research team members approached patients waiting for a regularly scheduled medical appointment with their primary care physician to complete the survey. Paper copies were stored in a locked filing cabinet within a locked office. The family medical center was located in a rural area of a state in the Southeastern United States. The family medical center where the research took place also housed a mental health provider who received referrals from the medical doctors at the same site. The research team asked permission to collect data on-site, and the lead physician at the center agreed. The mental health provider provides services to many of the same patients who receive medical care at the office. This study was part of a larger, quantitative research investigation on mental health, mental health stigma, and MHL (Crowe et al., 2018). Because of the expansive nature of the dataset, however, this article only focuses on the qualitative components of the survey.
Participants
Using published guidelines for in-person recruitment, the research team approached patients as they waited in the waiting room and asked if they would be interested in joining the research study (Felsen, Shaw, Ferrante, Lacroix, & Crabtree, 2010). When participants elected to participate in the study, they completed an informed consent and survey in the waiting area or in an exam room while waiting for the medical professional. All data were collected over the course of approximately six months. Incentives were not offered to participants and all participants could choose to opt out of participation at any time.
Participants included 102 individuals, including 65 females (63.7%) and 37 males (36.3%). A total of 70 participants identified as White (68.6%), 25 identified as Black/African American (24.5%), four identified as multiracial (3.9%), two did not know or endorsed the “other” category (2%), and one identified as Asian (1%). Regarding age, 30 (29%) participants were age 60 and above, 21 (21%) were between the ages of 50–59, another 21 (21%) were between the ages of 40–49, 14 (14%) were between the ages of 30–39, 14 (14%) were between the ages of 19–29, and two (2%) were 18 or younger. Fifty-six participants (55%) were married, while 27 (26%) were single. A total of 15 (15%) were separated/divorced, and four (4%) were widowed. One hundred and twelve participants were asked to complete the survey, and102 individuals completed the materials, yielding a 91% useable response rate. Demographic information is summarized in Table 1.
Table 1
Demographic Information
| Characteristic |
n |
% |
| Gender |
|
|
| Male |
37 |
36.3 |
| Female |
65 |
63.7 |
| Ethnicity |
|
|
| African American/Black |
25 |
24.5 |
| Caucasian/White |
70 |
68.6 |
| Multicultural |
4 |
3.9 |
| Other |
2 |
1.9 |
| Asian |
1 |
0.9 |
| Age |
|
|
| 18 or younger |
2 |
1.9 |
| 19–29 |
14 |
13.7 |
| 30–39 |
14 |
13.7 |
| 40–49 |
21 |
20.6 |
| 50–59 |
21 |
20.6 |
| 60+ |
30 |
29.4 |
| Marital status |
|
|
| Married |
56 |
54.9 |
| Single |
27 |
26.5 |
| Separated/Divorced |
15 |
14.7 |
| Widowed |
4 |
3.9 |
| Seeking treatment for |
|
|
| Physical health concerns |
88 |
86.3 |
| Mental health concerns |
3 |
2.9 |
| Both |
2 |
2 |
| Treatment status |
|
|
| Never sought treatment |
54 |
52.9 |
| Sought treatment in the past |
48 |
47.1 |
| Length of treatment |
|
|
| 1 year or less |
18 |
17.6 |
| 1–4 years |
11 |
10.8 |
| 5–10 years |
9 |
8.8 |
| 11–25 years |
5 |
4.9 |
| Description of treatment |
|
|
| Not at all helpful |
1 |
1 |
| Somewhat helpful |
9 |
8.8 |
| Generally helpful |
10 |
9.8 |
| Very/Extremely helpful |
28 |
23.3 |
| Family mental health |
|
|
No immediate family member with
a mental illness |
66 |
64.7 |
Immediate family member with a
mental illness |
26 |
25.4 |
| Not sure |
10 |
9.8 |
| Would you seek treatment for mental health concerns in the future? |
|
|
| Yes |
78 |
76.5 |
| No |
3 |
2.9 |
| Not sure |
21 |
20.5 |
Measures
For purposes of the current analysis, an open-ended question prompted participants: “In your own words, please describe what you believe the term mental health refers to.” Analysis was completed by comparing and contrasting the participant responses to this prompt with the U.S. Department of Health and Human Services (HHS; 2019) definition of mental health. This definition states that:
Mental health includes emotional, psychological, and social well-being. It affects how we think,
feel, and act. Mental health helps determine how we handle stress, relate to others, and make
choices. It is important at every stage of life, from childhood and adolescence through adulthood.
. . . Many factors contribute to mental health problems, including: biological factors, such as
genes or brain chemistry; life experiences, such as trauma or abuse; [and] family history of mental
health problems. (para. 1–2)
We elected to use this definition as opposed to similar definitions of mental health offered by WHO or the CDC because each member of the research team chose it as the most comprehensive of the three. Although there were many overlaps in the three definitions (i.e., all three descriptions mention well-being and handling or adjusting to stressors, and included some dimension of biological, psychological, and social aspects), the HHS definition also included the notion of life stages, past life experiences, and how these factors impact mental health.
Data Analysis
The deductive qualitative analysis method (Gilgun, 2011) was used to analyze participant responses to the open-ended prompt. In deductive coding, the researchers begin with existing codes, as deductive coding is utilized to test existing theories or frameworks. Because the current research was attempting to test the HHS definition, deductive analysis was considered the most fitting analysis method by the research team.
Deductive analysis attempts to understand how a particular theory or framework is useful or not (Gilgun, 2011). In deductive coding, data is sorted as it fits with existing concepts, or codes, within a framework. Deductive coding includes levels of analysis, including open coding, axial coding, and selective coding (Strauss & Corbin, 1990). According to Gilgun (2011), during open coding, the data is read line by line, sentence by sentence, and is placed as it is understood within the existing concept(s) with which it best aligns. Axial coding then occurs to refine the existing theory or framework via further analysis of data that is already placed within concepts. This data is then reconsidered to attend to groupings or subthemes within the concept to see if further details of a theory/framework are possible. Selective coding within deductive analysis is when the data is further examined to see if there is possible reduction to a single category or core concept. Selective coding is also an attempt to refine and further consider the existing framework to determine its utility and add to its use. As well, lines or sentences that do not fit existing concepts are noted. This is referred to as negative case analysis.
In the current research, the open coding analysis process was conducted repeatedly to consider and reconsider the data and its fit to the concepts within the HHS (2019) definition of “think, feel, and act.” These three concepts in the HHS definition were evident as the most salient. To aid in coding, these three HHS concepts were further understood by utilizing several online dictionaries (e.g., Google dictionary, Merriam-Webster, dictionary.com, and Cambridge English Dictionary) to define each concept. For example, the think code included all participant responses that are associated with this term via dictionaries, including intellectual, cerebral, brain, cognitive, and rational. The research team continually used several dictionaries to understand participant responses that were not exact or clear upon first reading. For example, state of mind was coded as think because of it being defined as a cognitive process and the condition of a person’s thoughts. Axial coding then occurred through the research team reconsidering the fit of the responses to the existing codes and if further codes could be developed via negative case analysis. As demonstrated below, axial coding produced a negative case analysis, that of overall well-being. Selective coding occurred through the team considering all codes and the utility of the original framework or, in this case, the HHS definition. This utility or lack thereof is further considered in the discussion below.
The entire analysis process was completed by two members of the research team independently. Independent coding enhances credibility in the analysis process, a technique promoted among qualitative researchers (Lincoln & Guba, 1985). The two researchers met on two occasions to discuss their findings and found consistency in their coding in both meetings. This consistency is often found when pre-existing codes with set definitions are utilized, as was the case in this analysis.
Results
The following section presents the results of the deductive coding of the data in comparison to the HHS definition of mental health, specifically the concepts of how we “think, feel, and act.” The existing concepts used as codes for analysis included the psychological, emotional, and social well-being—how we think, feel, and act. Sample quotes from participants (Ps) are provided. The research team also presents further points of possible refinement of the definition and sense of a core concept.
Concepts Used to Describe Mental Health
Think, feel, and act. Only 15 participant responses provided support for a definition of mental health that encompassed all three aspects found in the HHS (2019) definition of “think, feel, and act.” One participant stated, “mental health to me personally is the state of one’s condition of emotional, mental, social and physical well-being” (P2), and another shared that mental health is the “ability to succeed, fully participate in social, emotional and occupational and recreational leisure” (P3). Thus, there was only a small subset of participants who viewed mental health as comprehensively as federally defined.
Well-being. It should be noted that although most participants did not provide comprehensive definitions that specifically mentioned all three concepts of think, feel, and act, as used by HHS, there were 23 participants in the sample who used the term well-being. As indicated in the following, well-being was not seen as specific to one area but rather an overall experience. One participant stated, “More than a sense of psychiatric disease—overall well-being” (P4), and another shared, “Overall health of a person—their well-being” (P5). Thus, for many of our participants, a comprehensive definition of mental health they demonstrated was the general term well-being.
Think. The most salient concept found among our participants was related to cognition, thinking, the mind or brain, or the term mental. Thirty-four responses focused solely on mental health as being how we think, including statements such as “state of mind” (P6), “mental health refers to your thoughts” (P7), and “brain imbalance” (P8). These responses suggest that the cognitive aspect of mental health is a primary way these rural participants conceptualize mental health. We also saw this demonstrated in other definitions provided by the participants that had think in combination with either feel or act.
Think and feel. The next most salient conceptualization provided by participants included elements of both cognition and emotion—how we think and feel. Eighteen participants provided responses in this code, including “mental health is my ability to cope, how I think, rational thinking, and my emotional stability” (P9) and “state of mind and feeling of well-being” (P10). It is noteworthy that again when discussing cognition and emotion, there was frequent use of the phrase well-being, even when limited to just think and feel, thus further supporting the term well-being.
Think and act. Cognition or thinking was further salient and used in connection with behavior, or how we think and act. Conceptualizations from these 10 participants included statements such as “condition of one’s mind and if any affect [sic] on behavior” (P11) and “well-being in thought and action” (P12). Again, also noted is the use of the term well-being, even when specifying think and act.
Non-salient concepts within the HHS definition. There were other conceptualizations of the term mental health that supported aspects of the HHS definition. There were seven participants who focused solely on feelings—how you feel. Although there were five participants who only focused on mental health as behavior or how one acts, neither of the singular concepts were considered salient in participant responses because of infrequent responses.
Other non-salient concepts. Also provided by participants were concepts focused specifically on a mental health diagnosis such as “depression” (P16, P17) and “depression, bipolar” (P18). Also, it is interesting to note that although not salient, a few participants saw mental health as a function of physical health. This was demonstrated in definitions such as “condition of health” (P19) and “special help for the sick or assist those that have some type of disease” (P20). It is important to note that a few responses were unclear or too vague and could not be categorized, such as “Don’t know” (P21, P22).
Summary
Overall, participants’ responses suggest a strong tendency toward cognitive aspects of mental health rather than a comprehensive definition that can be found when looking in formal sources, such as the HHS definition (2019). However, a negative case that emerged was that these rural participants did provide the term well-being as an overall comprehensive definition for mental health. Frequency counts for each concept can be found in Table 2. In the following section, we discuss these findings.
Table 2
Frequencies According to HHS Definition Code
HHS Definition Codes Participant Response Count
Think 34
Think and Feel 18
Think, Feel, and Act 15
Think and Act 10
Well-Being 23
Discussion
In the current study, we explored MHL, specifically focusing on the efficacy of the HHS mental health definition in a rural, Southeastern U.S. sample. We sought to understand how this population conceptualized the term mental health. The current research literature provides very little information about this topic, so the following study offered initial findings to offer professional counselors and researchers implications and areas for further investigation.
It is important to reflect on the ways results from this sample of rural residents compare to the existing knowledge about the larger public’s MHL levels and ideas about mental health. Jorm (2000, 2012) noted that lack of MHL among individuals inhibits their ability to recognize mental health concerns when they arise. Although MHL may be an area for more intensive focus across all populations and settings (Jorm, 2000, 2012), results from this study suggest that there are a number of unique considerations in rural areas. Moreover, it is important to situate the current findings in the context of the challenges faced by rural residents. Knowing how those in rural communities define mental health, in their own words, will lend mental health practitioners information about how to communicate and connect effectively to increase the utilization of mental health services, improve the quality of care, and enhance clients’ ability to communicate concerns. If there are to be greater gains in prevention, intervention, and management of mental health in rural regions of the United States, a nuanced understanding of perceptions about mental health may offer a starting point.
Well-Being
In terms of the HHS definition, the current sample supported the concept of well-being. Although well-being was not necessarily connected concretely to the specific terms of think, feel, and act, it was often associated with one or two other concepts as well as used singularly as a holistic definition. Research on well-being has been of increasing interest in the past two decades (Dodge, Daly, Huyton, & Sanders, 2012), and many of the current national and international definitions of mental health refer to well-being (LaPlaca, McNaught, & Knight, 2013). Recent attempts have been made in the literature to more clearly articulate the definition of well-being (Dodge et al., 2012; LaPlaca et al., 2013), as this concept is being used to determine policy and practice on many national stages.
Current definitions of well-being combine elements of the psychological, social, and physical. However, these descriptions also focus on the ratio of resources to challenges that individuals and communities experience, and some have described well-being as the equilibrium between the two (Dodge et al., 2012). Thus, well-being should be considered within the context of social issues, economics, and service provision. This definition of well-being can be particularly useful for rural communities and populations, as resources and service provision are often lacking in rural communities (Health Resources & Services Administration, 2011). Our finding that participants connected with and utilized the concept of well-being suggests that both counseling practitioners and researchers should utilize the term and seek to better understand it, especially those working with rural communities and clients. However, participants in the current study did not provide an expansive level of detail in their conceptualization of well-being; rather, they focused on the cognitive or physical aspect of well-being.
Cognitive and Biological Focus
When comparing the current sample’s definitions to the HHS definition of mental health, the think/cognitive aspect of mental health was most supported and relevant to these rural participants. Most participants believed that mental health describes how individuals think, followed by those who described it as a combination of thoughts and feelings. As noted in the literature review, HHS (2019) considers mental health as impacting the way individuals think, feel, and act. In the current sample, however, only a small fraction of participants defined mental health as a combination of thoughts, feelings, and behaviors. Instead, participants considered mental health from a cognitive and biological perspective, focusing on the brain and chemical imbalances. Thus, results of this study suggest that individuals in rural communities might lack a holistic understanding of mental health.
Our findings add to the literature by providing context for rural individuals’ perceptions and possible explanations for treatment and help-seeking patterns. Rural residents may be especially vulnerable to misinformation about mental health disorders because of mental illness stigma, a cultural expectancy of self-reliance to resolve mental health concerns, and ascertaining mental health–related information from nonprofessionals (e.g., family members, religious leaders; Smalley et al., 2012; Snell-Rood et al., 2017), thus further underscoring the importance of improving MHL in rural communities. In the current study, for example, many participants listed only one component of mental health (e.g., brain imbalance, thoughts), suggesting that their understanding of the concept of mental health is lacking. The focus on the biological composition of the brain in mental health is consistent with definitions of mental illness promoted by organizations such as the National Institute of Mental Health. Thus, although participants’ definitions of mental health are not incorrect, in many ways the focus is narrow and not comprehensive. Study participants excluded emotions and when speaking about biology focused on the brain, which potentially discounts somatic manifestations of mental illness (e.g., stomach pains).
A more comprehensive understanding of mental health, with a specific focus on the connection between emotions, behaviors, and somatic symptoms, could potentially assist rural residents with becoming more conscious of signs and symptoms related to common mental health concerns such as anxiety and depression (Kim et al., 2015). It seems important for mental health educators, organizations, and counseling practitioners in rural communities to provide education that broadens the beliefs about the nature of mental health. Educational campaigns and direct work that are more inclusive and broadly focused could be of benefit.
Implications for Professional Counselors
Professional counselors and related mental health practitioners in rural areas noted they need training opportunities focused on clinical issues that are important in rural settings (Fifield & Oliver, 2016). Thus, the results from this study may offer mental health professionals guidance for reaching residents in rural communities and providing efficacious mental health services. Foremost, counselor training programs could consider developing courses with a specific focus on rural populations, which can assist counseling students in increasing their understanding of the culture of rural settings, how rural residents comprehend mental illness, and effective counseling practices in rural communities (Crumb, Mingo, & Crowe, 2019; Rollins, 2010). For example, counselors in training would be privy to facts such as how many people living in rural areas across the United States face additional life stressors, including poverty and housing and food insecurities, that impact their mental health and well-being.
The results of this study also illustrate the importance of building partnerships and collaborative relationships in rural communities, as rural residents may present varied concerns (e.g., concerns about physical health, family members, finances, spirituality) to counselors when seeking help. Thus, building both informal and formal professional support networks in rural communities is vital. Counselors in rural communities may consider building resources with physicians, faith-based organizations, and other mental health providers for consultation purposes (Avent, Cashwell, & Brown-Jeffy, 2015; Crumb, Mingo, & Crowe, 2019).
El-Amin et al. (2018) suggested programs such as rural-focused Mental Health First Aid to help increase MHL in rural communities. Because access to mental health services is often limited and/or non-existent in rural communities, counselors and related mental health professionals should be more intentional in implementing these forms of programming because of the large number of residents who reside in rural communities who have not yet been helped (El-Amin et al., 2018). Trainings such as this may assist with MHL, as well as mental health stigma, which has been associated with MHL in rural areas (Crowe et al., 2018).
Last, the focus on cognition in participants’ definitions of mental health may indicate a positive response to more cognitive-based theories such as CBT (A. T. Beck, 1970) and rational emotive behavioral therapy (Ellis, 1962). As this study was framed through the lens of CBT and the notion that cognition impacts emotions and behaviors, this theory and related interventions may fit well when working with clients in the rural United States. This type of “matching” related to how clients in the rural parts of the United States understand mental health (with a more cognitive focus) might lead to increased participation in counseling and therapy in rural areas. This might be a way for practitioners to join with the client initially, at the beginning of the therapeutic relationship, in order to “speak the same language.” However, given the findings of the current study, although individuals may have a natural inclination toward more cognitively focused theories, it is incumbent upon mental health professionals to challenge individuals to consider the ways emotions and behaviors are connected to their mental health as well. CBT fits this model well; however, scholars have also found ways to integrate other theories to provide an even more comprehensive and culturally responsive theoretical framework for clients. For example, one of the suggested interventions in Crumb and Haskins’ (2017) integration of CBT and relational cultural theory is to “apply cognitive restructuring through relational resilience” (p. 268). This technique could be especially beneficial to rural communities, as it honors the focus of cognitions while also considering how these thoughts and messages may be related to a broader systemic and environmental influence (Crumb & Haskins, 2017).
In sum, counselors should be aware that many of their clients may present with low MHL. Thus, education and awareness about mental health, diagnoses, and symptomatology may be an integral part of the treatment process. Counselors should consider this intentionality in education as a part of their role as advocates for their clients (Crumb, Haskins, & Brown, 2019).
Limitations and Future Directions
As with all research, the current study is not without limitations. First, the qualitative responses received from participants were often brief. The study team was able to analyze responses, but future qualitative research on the topic of MHL in rural samples might include a focus group design or individual interviews rather than paper-and-pencil surveys to get an in-depth look at how those in rural areas define mental health. Also, future research could seek to further understand the concept of well-being as used by rural participants, looking more in depth at all components (cognition, emotion, and behavior). Future research studies could also investigate the reasons for a focus on cognitive aspects of mental health. As it is impossible to separate cognition from emotion and behavior, this study found that many participants seemed to focus on cognition rather than a more comprehensive understanding of cognition as it related to choices in behaviors and affect. The current study took place in a medical center, and participants who were approached to participate may have felt pressure to complete the survey or answer in a way that was socially desirable. The sample was a convenience sample and may not be representative of others in the rural Southeast.
Large scale quantitative studies might offer scholars interested in MHL the opportunity to use validated instruments to measure literacy and perceptions about mental health in rural samples. Assessments such as the Mental Health Knowledge Schedule (Evans-Lacko et al., 2010) have been used in recent research (Crowe et al., 2018) to measure mental health knowledge. The Revised Fit, Stigma, & Value Scale (Kalkbrenner & Neukrug, 2018) is another scale measuring barriers to counseling such as stigma, values, and personal fit. These types of assessments can measure levels of recognition, familiarity, and attitudes toward mental health conditions in order to measure MHL and perceptions of mental health stigma.
Conclusion
This qualitative study investigated the HHS definition of mental health to determine if it was representative of rural Southeastern participants’ definitions. This assisted with answering the call for more research on the mental health of rural residents (Simmons, Yang, Wu, Bush, & Crofford, 2015) in order to provide better services to this population. Most participants demonstrated a conceptualization that included cognition, as well as well-being, and were more concrete in their conceptualization of mental health when compared to the more comprehensive HHS definition. A promising result from this study was that many participants seemed willing to seek mental health treatment in the future. Rural communities could benefit from mental health education with a holistic approach. Future research should consider interviewing rural populations to gather more detail on their definitions and understanding of mental health. The results provided interventions for professional counselors and related mental health clinicians, particularly those in rural settings, to integrate into their present work, pointed to the need for educational campaigns on mental health in rural areas, and highlighted areas for future research exploration.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Alang, S. M. (2015). Sociodemographic disparities associated with perceived causes of unmet need for mental health care. Psychiatric Rehabilitation Journal, 38, 293–299. doi:10.1037/prj0000113
Avent, J. R., Cashwell, C. S., & Brown-Jeffy, S. (2015). African American pastors on mental health, coping, and help seeking. Counseling and Values, 60, 32–47. doi:10.1002/j.2161-007X.2015.00059.x
Baker, D. W., Wolf, M. S., Feinglass, J., Thompson, J. A., Gazmararian, J. A., & Huang, J. (2007). Health literacy and mortality among elderly persons. Archives of Internal Medicine, 167, 1503–1509. doi:10.1001/archinte.167.14.1503
Beck, A. T. (1970). Cognitive therapy: Nature and relation to behavior therapy. Behavior Therapy, 1, 184–200. doi:10.1016/S0005-7894(70)80030-2
Beck, J. S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York, NY: Guilford Press.
Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annuals of Internal Medicine, 155, 97–107.
doi:10.7326/0003-4819-155-2-201107190-00005
Bryant, K., Moore, T., Willis, N., & Hadden, K. (2015). Development of a faith-based stress management intervention in a rural African American community. Progress in Community Health Partnerships: Research, Education, and Action, 9, 423–430. doi:10.1353/cpr.2015.0060
Crowe, A., Mullen, P. R., & Littlewood, K. (2018). Self-stigma, mental health literacy, and health outcomes in integrated care. Journal of Counseling & Development, 96, 267–277. doi:10.1002/jcad.12201
Crumb, L., & Haskins, N. (2017). An integrative approach: Relational cultural theory and cognitive behavior therapy in college counseling. Journal of College Counseling, 20, 263–277. doi:10.1002/jocc.12074
Crumb, L., Haskins, N., & Brown, S. (2019). Integrating social justice advocacy into mental health counseling in rural, impoverished American communities. The Professional Counselor, 9, 20–34. doi:10.15241/lc.9.1.20
Crumb, L., Mingo, T. M., & Crowe, A. (2019). “Get over it and move on”: The impact of mental illness stigma in rural, low-income United States populations. Mental Health & Prevention, 13, 143–148. doi:10.1016/j.mhp.2019.01.010
Deen, T. L., & Bridges, A. J. (2011). Depression literacy: Rates and relation to perceived need and mental health service utilization in a rural American sample. Rural and Remote Health, 11, 1803. Retrieved from http://www.rrh.org.
au/articles/subviewnew.asp?ArticleID=1803
Dodge, R., Daly, A. P., Huyton, J., & Sanders, L. D. (2012). The challenge of defining wellbeing. International Journal of Wellbeing, 2, 222–235. doi:10.5502/ijw.v2i3.4
El-Amin, T., Anderson, B. L., Leider, J. P., Satorius, J., & Knudson, A. (2018). Enhancing mental health literacy in rural America: Growth of Mental Health First Aid program in rural communities in the United States from 2008–2016. Journal of Rural Mental Health, 42, 20–31. doi:10.1037/rmh0000088.supp
Ellis, A. (1962). Reason and emotion in psychotherapy. Oxford, England: Lyle Stuart.
Evans-Lacko, S., Little, K., Meltzer, H., Rose, D., Rhydderch, D., Henderson, C., & Thornicroft, G. (2010). Development and psychometric properties of the mental health knowledge schedule. The Canadian Journal of Psychiatry, 55, 440–448. doi:10.1177/070674371005500707
Felsen, C. B., Shaw, E. K., Ferrante, J. M., Lacroix, L. J., & Crabtree, B. F. (2010). Strategies for in-person recruitment: Lessons learned from a New Jersey Primary Care Research Network (NJPCRN) study. The Journal of the American Board of Family Medicine, 23, 523–533. doi:10.3122/jabfm.2010.04.090096
Fifield, A. O., & Oliver, K. J. (2016). Enhancing the perceived competence and training of rural mental health practitioners. Journal of Rural Mental Health, 40, 77–83. doi:10.1037/rmh0000040
Fuller, J. D., Edwards, J., Procter, N., & Moss, J. (2000). How definition of mental health problems can influence help seeking in rural and remote communities. Australian Journal of Rural Health, 8, 148–153.
doi:10.1046/j.1440-1584.2000.00303.x
Gilgun, J. (2011). Coding in deductive qualitative analysis. Current Issues in Qualitative Research: An Occasional Publication for Field Researchers from a Variety of Disciplines, 2, 1–4.
Gore, J. S., Sheppard, A., Waters, M., Jackson, J., & Brubaker, R. (2016). Cultural differences in seeking mental health counseling: The role of symptom severity and type in Appalachian Kentucky. Journal of Rural Mental Health, 40, 63–76. doi:10.1037/rmh0000041
Hastings, S. L., & Cohn, T. J. (2013). Challenges and opportunities associated with rural mental health practice. Journal of Rural Mental Health, 37, 37–49. doi:10.1037/rmh0000002
Health Resources & Services Administration. (2011). Designated mental health care health professional shortage areas. Retrieved from https://data.hrsa.gov/topics/health-workforce/shortage-areas
Jameson, J. P., & Blank, M. B. (2007). The role of clinical psychology in rural mental health services: Defining problems and developing solutions. Clinical Psychology: Science and Practice, 14, 283–298.
doi:10.1111/j.1468-2850.2007.00089.x
Jorm, A. F. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders. British Journal of Psychiatry, 177, 396–401. doi:10.1192/bjp.177.5.396
Jorm, A. F. (2012). Mental health literacy: Empowering the community to take action for better mental health. American Psychologist, 67, 231–243. doi:10.1037/a0025957
Kalkbrenner, M. T., & Neukrug, E. S. (2018). Identifying barriers to attendance in counseling among adults in the United States: Confirming the factor structure of the Revised Fit, Stigma, & Value Scale. The Professional Counselor, 8, 299–313. doi:10.15241/mtk.8.4.299
Kim, J. E., Saw, A., & Zane, N. (2015). The influences of psychological symptoms on mental health literacy of college students. American Journal of Orthopsychiatry, 85, 620–630. doi:10.1037/ort0000074
Kutcher, S., Wei, Y., & Coniglio, C. (2016). Mental health literacy: Past, present, and future. The Canadian Journal of Psychiatry, 61, 154–158. doi:10.1177/0706743715616609
La Placa, V., McNaught, A., & Knight, A. (2013). Discourse on wellbeing in research and practice. International Journal of Wellbeing, 3, 116–125. doi:10.5502/ijw.v3i1.7
Lincoln, Y., & Guba, E. (1985). Naturalistic inquiry. Newbury Park, CA: SAGE.
National Alliance on Mental Illness. (2015). Mental health by the numbers. Retrieved from http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers
National Council for Behavioral Health. (2019). Mental Health First Aid. Retrieved from https://www.thenationalcouncil.org/about/mental-health-first-aid/
Office of Rural Health Policy. (2005). Mental health and rural America: 1994–2005. Rockville, MD: Author. Retrieved from https://www.ruralhealthresearch.org/mirror/6/657/RuralMentalHealth.pdf
Rainer, J. (2012, Fall). The state of rural mental health: Caring and the community. The National Register of Health Service Providers in Psychology, 8–13.
Rollins, J. (2010, April). Learning the ropes of rural counseling. Counseling Today. Retrieved from https://ct.counseling.org/2010/04/learning-the-ropes-of-rural-counseling/
Rural Health Information Hub. (2017). Rural mental health. Retrieved from https://www.ruralhealthinfo.org/topics/
mental-health
Simmons, L. A., Yang, N. Y., Wu, Q., Bush, H. M., & Crofford, L. J. (2015). Public and personal depression stigma in a rural American female sample. Archives of Psychiatric Nursing, 29, 407–412. doi:10.1016/j.apnu.2015.06.015
Smalley, K. B., Warren, J. C., & Rainer, J. P. (Eds.). (2012). Rural mental health: Issues, policies, and best practices. New York, NY: Springer.
Snell-Rood, C., Hauenstein, E., Leukefeld, C., Feltner, F., Marcum, A., & Schoenberg, N. (2017). Mental health treatment seeking patterns and preferences of Appalachian women with depression. American Journal of Orthopsychiatry, 87, 233–241. doi:10.1037/ort0000193
Stewart, H., Jameson, J. P., & Curtin, L. (2015). The relationship between stigma and self-reported willingness to use mental health services among rural and urban older adults. Psychological Services, 12, 141–148. doi:10.1037/a0038651
Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques (2nd ed.). Newbury Park, CA: SAGE.
U.S. Department of Health & Human Services. (2019). What is mental health? Retrieved from https://www.mentalhealth.
gov/basics/what-is-mental-health/
World Health Organization. (2013). Integrating mental health services into primary health care. Retrieved from https://www.who.int/mental_health/policy/services/3_MHintoPHC_Infosheet.pdf
Allison Crowe is an associate professor at East Carolina University. Paige Averett is a professor at East Carolina University. Janeé R. Avent Harris, NCC, is an assistant professor at East Carolina University. Loni Crumb, NCC, is an assistant professor at East Carolina University. Kerry Littlewood is an instructor at the University of South Florida. Correspondence can be addressed to Allison Crowe, 225 Ragsdale Hall, Mailstop 121, College of Education, 5th St., Greenville, NC 27858, crowea@ecu.edu.
Mar 26, 2019 | Volume 9 - Issue 1
J. Richelle Joe, M. Ann Shillingford-Butler, Seungbin Oh
In this phenomenological study, the authors explored the lived experiences of 19 African American mothers raising boys and young men to understand how media exposure to community and state violence connects to the physical and mental health of these mothers. Analysis of semi-structured individual interviews revealed six themes: psychological distress, physical manifestations of stress, parenting behaviors, empathic isolation, coping strategies, and strengths. The analysis of the data revealed that these themes were connected such that community and state violence were forces weighing on these mothers, resulting in emotional responses, changes to parenting approaches, physical responses, and empathic isolation, while the mothers’ coping strategies and strengths served as forces to uplift. The authors present the lived experiences of the participants through a discussion of these themes and their implications for counseling African American mothers within the current social–political context.
Keywords: African American mothers, #BlackLivesMatter, community and state violence, media exposure, mental health
During the 2016 Democratic National Convention, seven African American women took the stage in solidarity to shine a light on community and state violence and the need for criminal justice reform (Drabold, 2016; Sebastian, 2016). These women, collectively referred to as the “Mothers of the Movement,” included Lesley McSpadden, Gwen Carr, and Lucy McBath, the mothers of Michael Brown, Eric Garner, and Jordan Davis, respectively—young African American males whose deaths were widely publicized as examples of gun violence (community violence) or police use of force (state violence). Sybrina Fulton also was in attendance. The death of her son, Trayvon Martin, in 2012 sparked a modern conversation about violence against African Americans and led to the creation of the #BlackLivesMatter movement (Black Lives Matter, n.d.). During their address to the convention, the “Mothers of the Movement” shared their grief publicly and spoke on behalf of their children, with Fulton emphatically stating: “This isn’t about being politically correct. This is about saving our children” (Drabold, 2016).
Sixty-one years earlier, Mamie Till had similarly allowed the world to see her grief as she wept over the open casket of her 14-year-old son, Emmett, who had been brutally murdered for being a young Black man in the Deep South (CBS News, 2016). Like the death of Trayvon Martin, Emmett Till’s death galvanized the African American community and motivated activists—including Rosa Parks—to participate in the modern civil rights movement (CBS News, 2016). By sharing the intense pain experienced by a mother’s loss of a child to violence, Mamie Till and the “Mothers of the Movement” allowed others to share in their grief.
As written by Sybrina Fulton (2014, para 9) in a letter to Lesley McSpadden, “If they refuse to hear us, we will make them feel us . . . feeling us means feeling our pain; imagining our plight as parents of slain children.” The pain experienced by these mothers was felt. Mothers of Black children extended sympathy and support to these mothers who had lost their children to community or state violence (Stewart, 2017).
One such letter, penned by university professor Melissa Harris-Perry, illustrates the emotional connection felt among women who saw their own children reflected in the faces of Michael Brown, Trayvon Martin, and Tamir Rice. According to Harris-Perry (2014, para 8), many Black mothers “felt your anguish through the screen, felt it penetrate our core and break our hearts as we bore witness to your shock and torment.” Statements such as this indicate that the public and violent losses experienced by African American mothers, both past and present, resonate within the African American community and particularly affect other African American mothers, even those who have not experienced such a loss. How African American mothers are affected by bearing witness to the public deaths of African Americans as a result of community and state violence is not fully known. Hence, the purpose of this study was to investigate the experiences of African American mothers who have been exposed to state and community violence while raising their sons to understand how this exposure connects to their physical and mental health.
The experiences communicated by the women mentioned above suggest that parenting for these women is in some way unique and shaped by the social and racial contexts in which they live. Research on parenting in general, and parenting stress specifically, has indicated that experiences and context affect the lives of parents in particular ways. Cumulative exposures to life stressors, such as those associated with limited availability of resources, can exacerbate parenting stress, mental strain, or tension related to the role of being a parent (Berry & Jones, 1995; Raphael, Zhang, Liu, & Giardino, 2010). For example, lack of financial resources aggravates parenting stress by draining parents’ emotional resources to respond empathetically to their children. Under high economic strain, parents are more likely to become preoccupied with managing finances (e.g., an overdue bill or loan default) and emotionally less available for their children, which negatively influences child development (Berk, 2013; Conger & Donnellan, 2007). Additionally, parents’ experiences with other daily stressors (e.g., work-related frustrations and burden) influence parenting behaviors and attitudes, which may create stressful home environments for children (Matjasko & Feldman, 2006).
African American mothers in low-income families have reported high rates of trauma and post-traumatic stress disorder (PTSD) symptoms, and their PTSD can predict parental distress (Cross et al., 2018). Such parental stress has been inversely related to positive parenting behaviors (Chang et al., 2004), which can result in negative outcomes for children. Stress among African American mothers exists regardless of family structure. Cain and Combs-Orme (2005) found co-caregiving with a spouse, partner, or other family member did not affect maternal stress or parenting behaviors. This research indicates that parental stress is prevalent among African American mothers whether they are single parents or co-parenting.
A contextual factor that may shed light on the experiences of parenting stress among African American mothers is race-based stress (Carter, 2007). According to Greer (2011), the negative, race-related experiences of African Americans are associated with negative psychological outcomes such as anxiety and depression. African American women in particular experience racism within the workplace, health care system, and educational settings (Greer, 2011). Racist microagressions play a key role in the psychological distress of African American women and significantly contribute to increased levels of stress and anxiety (Szymanski & Owens, 2009). Affective costs of racism among this disenfranchised group include depression, anxiety, and somatization (Pieterse, Todd, Neville, & Carter, 2012). Pieterse et al. (2012) reported trauma-like symptoms similar to PTSD among African Americans after prolonged episodes of racism.
Exposure to community and state violence exists as a particular type of race-based stress that strains the psyche of African Americans. Galovski et al. (2016) found that among community members in Ferguson, Missouri, following the killing of Michael Brown by a law enforcement officer, post-traumatic stress and depression were higher among African Americans than their White counterparts. Additionally, direct exposure to violence was not associated with distress, suggesting that media exposure or secondary exposure provided the sufficient context for mental health concerns to exist. Similarly, Bor, Venkataramani, Williams, and Tsai (2018) reported that African American residents in a state where police killings of unarmed African Americans occurred experience worse mental health following each incident. These effects were not evident for White residents in the same state, nor was there a similar effect for unarmed White residents or armed African American residents killed by police. According to Umberson (2017), exposure to violent death within the community is particularly difficult when the loss is that of a loved one. Such a loss within the African American community “launches a lifelong cascade of psychological, social, behavioral, and biological consequences that undermine other relationships, as well as health, over the life course” (Umberson, 2017, p. 407). The continued losses of young African American men to community and state violence present a collective threat and result in a sense of vulnerability within the African American community, as well as potentially contribute to an increase in health disparities among this population because of race-related stress.
African American mothers experience parenting stress as well as race-based stress, yet the extent to which race-based parenting stress exists for them is unknown. Research on African American mothers has explored their levels of stress and the relationship that parental stress has with their parenting behaviors and children’s outcomes (e.g., Cain & Combs-Orme, 2005; Chang et al., 2004; Cross et al., 2018; Kennedy, Bybee, & Greeson, 2014). However, often the research focus is on “at-risk” African American mothers such as adolescent mothers, single mothers, mothers experiencing intimate partner violence, and mothers in low-income households. Additionally, despite the abundance of research with samples of African American mothers, the exploration of their lived experiences as mothers who may be exposed to race-based stress vis-à-vis state and community violence is absent from the literature. Violence resonates through relationships and can be conceptualized as a reproductive health and social justice issue for African American women (Premkumar, Nseyo, & Jackson, 2017). Hence, this study sought to illuminate the experiences of African American women raising sons, allowing them the platform to speak their lived experiences as mothers in the current social and racial context.
Method
The following research question was examined: What are the lived experiences of African American mothers who have been exposed to community and state violence while raising their sons? The research team chose a qualitative approach, specifically phenomenological methodology. As a constructivist approach, phenomenology acknowledges the existence of multiple realities and allows for an understanding of the lived experiences of participants through their own voices. This methodology is congruent with the profession of counseling (Hays & Wood, 2011), and the researchers felt using phenomenology was particularly important given the focus on African American women who experience multiple layers of marginalization at the intersection of race and gender (Crenshaw, 1989).
Participants
Prior to participant recruitment, the Institutional Review Board at the authors’ university approved the study. The participants were recruited via purposive, criterion sampling to gain a sample of African American mothers with at least one son age 25 or younger at the time of the study. Recruitment materials were shared with African American women using direct electronic mail as well as social media. Participants also referred potential participants to the research team for inclusion in the study (snowball sampling). Research team members contacted all participants via direct electronic mail to provide them with details about the study, review the informed consent document, collect demographic information, and schedule the individual interview. Sample size recommendations for qualitative research such as the present study range from six to 12 participants (Creswell, 2013; Guest, Bunce, & Johnson, 2006; Onwuegbuzie & Leech, 2007). Hence, the research team sought to recruit 20 participants to account for the possibility of attrition.
In response to recruitment efforts, 22 individuals expressed interest in the study and were initially contacted by the researchers. Two of those individuals were unable to complete an individual interview, and another individual was eliminated because of poor audio recording quality. Hence, data from 19 participants were analyzed for this study. Further recruitment was deemed unnecessary as the sample size exceeded the recommended size and the data analysis reached saturation with data from these 19 participants.
The participants ranged in age from 31 to 61, with a mean age of 44.8. Their sons ranged in age from 2 to 35, though all had at least one son under age 25. All participants were high school graduates, and most had an advanced degree (52.6%). Additionally, most participants lived in two-parent households (52.6%) at the time of the study, earned an annual household income of more than $100,000 (42.1%), and lived in a suburban setting (57.9%). Participant profiles are provided in Table 1.
Data Collection and Analysis
The researchers conducted semi-structured individual interviews with the 19 participants, each lasting 20 to 60 minutes. All interviews were conducted over the phone, audio-recorded, and transcribed verbatim. The interview protocol consisted of the following questions: (a) What have your experiences been like being a mother of an African American boy or young man? (b) There have been several violent incidents reported by the media involving African American young men. How do you feel about these incidents? (c) Was there any particular incident that affected you the most? (d) How would you describe your overall mental and physical health? and (e) What would you say are your strengths as a mother? The interviewers provided follow-up questions and clarifying statements to participants when they were deemed necessary or when participants asked for clarification.
Once the interviews were transcribed, the research team analyzed the data in accordance with methods outlined by Moustakas (1994). First, the team immersed themselves in the data by reviewing each transcript individually. They divided the 19 transcripts between the two of them and read through them to become familiar with the data. For each transcript, they identified relevant statements that reflected the participants’ lived experiences (horizontalization) as African American mothers raising boys and young men within the contexts of structural racism and community and state violence. After going through this process individually, the research team met multiple times to review all transcripts and confer about these textural descriptions. The research team identified relevant codes and then synthesized the textural descriptions into themes by examining them for commonalities to distill the meaning expressed by the participants. Verbatim examples were extracted from the transcripts and used to generate a thematic and visual description of the phenomenon being examined. Once the initial data analysis was completed, the researchers conducted member checking by sending each participant their individual transcript as well as the written results section. Participants were asked to comment on the accuracy of their transcripts as well as the alignment of the results with their lived experiences. None of the participants reported any errors or additions to the transcripts, and none provided any additions or corrections to the themes provided in the results.
Table 1. Participant Demographic Information
| Participant |
Age |
Number of Male Children in Home |
Age(s) of Male Children |
Household Composition |
Education |
| 1 |
31 |
1 |
2 |
Multi-generational |
Bachelor’s Degree |
| 2 |
45 |
3 |
15, 20, 27 |
Two-parent |
Master’s Degree |
| 3 |
50 |
1 |
19 |
Two-parent |
Master’s Degree |
| 4 |
42 |
1 |
15 |
Two-parent |
Doctoral Degree |
| 5 |
48 |
1 |
23 |
Two-parent |
Master’s Degree |
| 6 |
43 |
2 |
2, 16, 19 |
Two-parent |
Master’s Degree |
| 7 |
46 |
1 |
16 |
One-parent |
Doctoral Degree |
| 8 |
61 |
1 |
20 |
One-parent |
Some College |
| 9 |
40 |
2 |
2.5, 5 |
Two-parent |
Bachelor’s Degree |
| 10 |
56 |
0 |
19 |
One-parent |
Master’s Degree |
| 11 |
47 |
1 |
18, 26 |
Two-parent |
Bachelor’s Degree |
| 12 |
43 |
1 |
10 |
Two-parent |
Doctoral Degree |
| 13 |
43 |
1 |
18 |
One-parent |
Bachelor’s Degree |
| 14 |
36 |
2 |
2, 7 |
Two-parent |
Bachelor’s Degree |
| 15 |
41 |
1 |
17, 21, 26 |
One-parent |
Doctoral Degree |
| 16 |
45 |
1 |
16 |
One-parent |
Master’s Degree |
| 17 |
42 |
1 |
12 |
Multi-generational |
Bachelor’s Degree |
| 18 |
35 |
1 |
9 |
One-parent |
Some College |
| 19 |
57 |
1 |
22, 35 |
Two-parent |
Bachelor’s Degree |
Trustworthiness and the Research Team
Qualitative research requires credibility, a key element of trustworthiness, such that the research findings accurately reflect the data (Lincoln & Guba, 1985). Reflexivity, wherein researchers critically examine their procedures with respect to power, privilege, and oppression, is a critical element of maintaining research credibility (Hunting, 2014). To safeguard against researcher bias, the researchers worked collaboratively to establish credibility throughout data collection and analysis. The research team consisted of two African American female faculty members at a large Southeastern university. Both were core faculty in the same counselor education program and have experience working as professional school counselors. To address researcher bias, the researchers engaged in bracketing to address the ways in which their experiences influence their approach to research and expectations of the outcomes of the study. Prior to the data collection, they discussed their experiences as African American women who have experienced systemic racism and are aware of state and community violence affecting the African American community. They identified their personal experiences and acknowledged their biases, attempting to put them aside as they conducted the interviews. Throughout the data collection and analysis, they engaged in personal reflection and maintained analytic memos chronicling their reactions and initial thoughts about the data being collected.
Prior to beginning data analysis, the research team met to confirm the analysis procedures to ensure consistency. They analyzed data individually and as a team and determined codes and themes jointly to reduce bias. They also consulted throughout the data analysis process to address questions or concerns regarding the data. They consulted with an outside researcher experienced in qualitative research to get critical feedback on the data analysis process and the research findings (Marshall & Rossman, 2006). This peer review was used as an external check of the research methodology and theoretical interpretation of the data.
Results
Six themes emerged from the data to illustrate the lived experiences of African American mothers who have been exposed to community and state violence while raising their sons: (a) psychological distress, (b) physical manifestations of stress, (c) parenting behaviors, (d) empathic isolation, (e) coping strategies, and (f) strengths. The analysis of the data revealed that these themes were connected such that community and state violence were forces weighing on these mothers, resulting in emotional responses, changes to parenting approaches, physical responses, and empathic isolation, while the mothers’ coping strategies and strengths served as forces to uplift. Below is a discussion of each theme using exemplars from the data to present the experiences of these mothers in their own words.
Psychological Distress
The participants in this study described the emotions they felt regarding community and state violence, with all of them expressing various levels of fear, anger, heartbrokenness, and exhaustion. Fear or anxiety was most prominent for these mothers, many of whom thought of their own sons when they heard stories about young African American men killed by gun violence at the hands of other citizens or by law enforcement officers. Some felt fear of the unknown, as in Participant 9 who stated, “Like, what will the world do to you?” Many expressed that the fear was persistent, as they seemed to ruminate over such shootings. In Participant 10’s words, “I see the pictures of those young men daily in my mind.” The fear that these mothers described relates directly to their sons in that they have a baseline fear that their son also will become a victim of state violence. Participant 2 described living with “an underpinning of terror,” adding that “my fear is that . . . one of my sons is going to be murdered by a police officer.” In addition to fear, the participants reported feelings of anger and outrage. Participant 5 stated that she considered purchasing a gun, although she did not articulate what she would do with it. For many of the mothers, their anger was closely associated with their experience of motherhood: “Before I had kids, I didn’t realize how angry I already was about the injustice . . . it just (caused) more anger and frustration” (Participant 9).
Feelings of being heartbroken, helpless, and psychologically exhausted emerged clearly from the data. Participants expressed disbelief upon hearing about police shootings of unarmed African American men and a lack of control about what Participant 7 referred to as “a cancer on society.” Participant 1 described the experience of feeling like she had been “hit with a rubber bullet, like, you know there’s no penetration, but it hurts all the same.” A particularly poignant statement from Participant 10 indicated that participants feel helpless and almost hopeless about the possibility that a change is possible: “I don’t even know what our children have to do to convince the world that they are children . . . or even that they are human.” Additionally, the mothers are mentally exhausted by reports of community and state violence against African American young men. Participant 1 described feeling burned out, tired, and “just one tipping point message away from a breakdown.”
Part of this exhaustion seemed to stem from a sense of proximity to the events in the news because of social media and 24-hour news cycles. Participants reported that they felt like the shootings were happening right in front of them, making them more aware of the existence of community and state violence. Some reported feeling numb to the media reports and others stopped watching the news or engaging with social media sites in an attempt to try to disconnect from reports they found overwhelming.
Physical Manifestations of Stress
The mothers in this study described the ways in which the exposure to community and state violence affected them physically. Some reported reactions that sounded like responses to trauma or some anxiety-provoking experience that were manifested in their physical bodies. Participant 1 felt “sick to my stomach . . . heart, you know like adrenaline pumping . . . like a tightness in my chest.” Participant 5 stated that after hearing about a recent police shooting and out of concern for the safety of her son, she “would be physically sick.” Additionally, participants reported a loss of sleep and difficulty relaxing. A response by Participant 14 illustrates the connection that the physical effects have to the psychological effects of community and state violence for these mothers: “I cried as though this was my child that had been killed . . . I was sick to my stomach . . . I had a pit in my stomach . . . and I also . . . became overly concerned about my son.” They were psychologically affected by incidents of state and community violence and those effects manifested physically as well as in their hypervigilance regarding their sons.
Parenting Behaviors
The participants described how their mothering has been shaped by their exposure to community and state violence. They reported being hypervigilant and overprotective in their parenting behaviors in an effort to protect their sons. These parenting behaviors included hovering over their sons, micromanaging their sons’ lives, and attempting to limit their sons’ movements. Participant 5 stated that she wanted to put a camera in her son’s car so that she could have an eye on him when he was driving. Participants described their efforts to keep their sons insulated, such as Participant 13’s statement that “I just try to keep my son as far away from it as I possibly can.” Participant 10 expounded on this behavior in great detail, stating “If I could have, I would have locked him in my house and just kept him there.” The mothers seemed to have a keen awareness that their parenting had become overly protective, and they experienced some ambiguity about it. One mother acknowledged that she parents her son and daughter differently and lamented that she may be limiting his cognitive development. Similarly, Participant 4 expressed concern that being overprotective might affect her son’s social life, yet her concern for his safety outweighed that concern, as evidenced by her statement that, “I don’t want that for him, but at the same time I need him to be alive.”
The participants also stated that they regularly have conversations with their sons about how to behave and present themselves to others. They reported increasing these conversations following incidents of community and state violence in the news. The conversations they have include how to carry themselves in a respectable way in public and how to make wise decisions when outside the home. Specifically, they have talked with their sons about what to do if stopped by the police. The participants described the conversations as ones that go beyond the typical lessons that parents teach their children in that these are conversations shaped by their experiences as African American mothers of African American sons. As Participant 5 stated “we’ve had to say things to them that their White friends don’t have to say.”
Empathic Isolation
In their description of the effects community and state violence have had on their emotions, physical bodies, and parenting, the participants also described an experience that the researchers have called empathic isolation. Participants described receiving little to no empathy from others outside of the home as well as a self-imposed masking of emotions within the home in an effort to protect their sons. The lack of empathy outside of the home seemed to be connected with the perceived White privilege of coworkers and community members. Participant 5 stated of such individuals: “I want you to feel my frustration and my anger”—yet those individuals did not. Participant 3 added that the responses that she heard from others after publicized incidents of community or state violence upset her because they reflected a lack of empathy and understanding. During the trial of George Zimmerman, Participant 10 was hopeful because the jury largely consisted of women. However, she was disappointed by the outcome of the trial and felt that the women on the jury saw Trayvon Martin as a Black male adult rather than a 16-year-old boy. She wondered how and when Black children would be seen as children rather than threats. As a result of this lack of empathy, many of the mothers reported masking their emotions in public spaces. Participant 19 stated, “I have to put on my face in the morning when I go into the workplace that has every ethnicity and just be me, not be that concerned mother.”
Similarly, at home the mothers reported holding their emotions close in an attempt to protect their sons. They expressed concern about their emotions affecting their sons, so they mask their emotions. Participant 18 described having to “put on” for her son, meaning that despite her sadness or concern, she had to “put on that face that everything is okay.” A single mother participant expressed how it is particularly difficult for her to allow herself to fully experience her emotions. She described feeling as though she had no choice but to be strong even in moments in which she feels weak. Both inside and outside of the home, these mothers feel a multitude of emotions, yet they do not feel fully free to express them and receive empathy, either because of the empathic failures of others or because they want to shield their sons and keep pushing forward.
Coping Strategies
Despite the stress they feel as mothers raising African American boys and young men, participants identified multiple ways in which they cope or care for themselves in the face of adversity. Some coping strategies were internal or individual, such as maintaining a positive outlook, engaging in self-care, journaling, and prayer or meditation. Reliance on faith was evident for many participants and for at least one participant was a means to fight oppression and liberate her son (Participant 10). Participants also discussed other ways of coping that had more of an external focus, such as connecting with other African American mothers and looking to their existent social network of family and friends for support. Several participants discussed either current involvement or a desire for future involvement in community activism to address systemic racism. These participants described a type of self-care motivated by a desire to see change and manifested in action to address the systemic racism that affected their lives and the lives of their sons.
Few of the participants (n = 4) reported seeking out and utilizing professional mental health services as a coping strategy. Participants gave multiple reasons for not seeking mental health services, including pragmatic ones, such as not having time or not being able to afford services. Participants also made statements such as “I just deal with it” (Participant 7) and “I feel like I can control it” (Participant 15), which seem to relate to the experience of wearing the mask discussed above with the theme of empathic isolation. Other statements by participants indicated that they have little confidence that counseling would help. Participant 14 stated plainly that there is no use in her seeking counseling if the systems that affect her son are still in existence. Participant 10 focused on what the experience in a counseling session would be like if she were to share her experiences and feelings as an African American mother raising a son. She described the potential exhaustion she would feel as a client, stating, “In terms of talking about the anxiety around racism and concern for my children, I just did not have the energy to seek any kind of help for that.”
Strengths
In response to the question about their strengths as mothers, participants identified several internal strengths that shape their parenting as well as the outward behaviors that characterize their motherhood. Among their internal strengths were responsibility, morality, unconditional love and acceptance, integrity, thinking big, being open and honest in communication, being informed and educated, having the ability to see purpose and strengths in their children, flexibility, resourcefulness, and resilience. Participant 10 gave a particularly powerful characterization of her strengths, stating, “I think . . . as African American women to go ahead and be mothers in the world that we live in, it’s a combination of crazy and brave.” With these internal strengths, the mothers reported being active on behalf of their children by giving them as many opportunities as possible, advocating for them when necessary, teaching them skills, building a social support network, and keeping their children as a priority.
Discussion
The aim of this study was to explore the experiences of African American mothers who have been exposed to state and community violence while raising their sons to understand how this exposure connects to their physical and mental health. Six themes emerged from the data: psychological distress, physical manifestations of stress, parenting behaviors, empathic isolation, coping strategies, and strengths. From the perspectives of these participants, state and community violence weigh down on them as African American mothers, negatively impacting their psychological and physical health and altering their parenting behaviors. Additionally, the interplay between their psychological distress and the change in their parenting facilitates an experience of empathic isolation, in which these mothers mask their emotions inside their homes so as not to adversely affect their sons, and mask their emotions outside of the home (e.g., in the workplace) as they interact with others who are either incapable or unwilling to provide empathic responses to their experiences. Further, participants identified clear personal strengths and coping strategies, such as devotion to their children and involvement in community activism, which were used to uplift themselves. Interestingly, the coping strategies for most of these women did not include seeking help from a mental health professional, even when they were aware of the psychological distress associated with exposure to community and state violence.
These results are both enlightening and disheartening. African American mothers live with daily fear for their sons of all ages. This fear exists despite most of the participants reporting that their sons had not been directly involved in or exposed to violence. These mothers constantly relive psychological trauma because of media exposure of incidents of community and state violence involving African American boys and young men. The results support sentiments of Galovski et al. (2016) that African American mothers are not concerned with just a few random incidents of violence, but rather are affected by greater, continuous, and systemic experiences of psychological trauma spanning decades. These continued distressing experiences of direct and indirect violence appear to negatively impact the psychological (e.g., anger, fear, outrage) and physiological (e.g., tightness in the chest) well-being of African American mothers and likely exacerbate existing health disparities for this population. Findings support previous research regarding the experience of ongoing race-related PTSD among African American mothers (Pieterse et al., 2012). Still, despite threats to their mental and physical health, African American mothers continue to press through with the hopes of protecting and empowering their sons using a cloak of resilience and buoyancy. Additionally, African American mothers wear a mask of courage and strength to educate their children about racism, resilience, and resistance without revealing their true emotions. DePouw and Matias (2016) highlighted the concept of critical race parenting, whereby parents of color work to educate, advocate, and protect their children from cultural racism. Based on the findings of this study, African American mothers continue to fight for access to safety and equality for their children, while simultaneously attempting to shield their sons from the psychological and physical health effects that community and state violence have on them as mothers.
Implications for Counselors
The results of this study provide insight into the experiences of African American mothers raising sons in the context of #BlackLivesMatter and can inform the work of mental health professionals regarding this population. Given that many African American mothers live with fear or anxiety regarding the safety of their sons, which affects their mental and physical health and parenting behaviors, practitioners might consider culturally sensitive and responsive methods to attract and retain these mothers as clients. An ideal start would be to seek to understand the social and historical context of the experiences of African Americans and the connection with current events of violence and racism. This exploration should be done not within the confines of counseling, but in preparation for building therapeutic rapport. Participants in this study reported possessing little faith that White counselors would understand or believe their experiences. This finding underscores the need for greater cultural competence among White mental health professionals and an increase in the number of available African American counselors to serve African American women. Additionally, work with African American mothers must be strengths-based, building upon the internal and external strengths and resources that exist within the lives of these women. Specifically, the sense of determination encapsulated in the phrase “crazy and brave,” used by one of the participants to describe herself, highlights the resourcefulness of African American mothers to provide for and protect their families. Counselors are encouraged to recognize and enhance such personal assets by highlighting the positive energy that these mothers bring to the therapeutic setting through their stories. Relational cultural theory (RCT) might be an appropriate framework to use in counseling clients like the women in this study. RCT centers the cultural experiences of clients and considers how systems of oppression and marginalization affect individuals and their relationships (Comstock, et al., 2008). The mutual empathy, mutual empowerment, and authenticity that are foundational in RCT can provide a therapeutic environment in which African American mothers can explore their experiences of disconnection, such as the empathic isolation that they described in this study.
Finally, mental health professionals need to consider the importance of social justice advocacy to address the community and state violence that negatively impacts the African American community at large and African American mothers of sons specifically. This, in fact, is an ethical obligation of professional counselors who advocate on multiple levels “to address potential barriers and obstacles that inhibit access and/or the growth and development of clients” (American Counseling Association, 2014, p. 5). The results of this study clearly indicate that community and state violence can be a barrier to optimal physical and mental health of African American mothers. The #BlackLivesMatter movement has created resources for individuals seeking to engage in advocacy and encourage open dialogue around issues of community and state violence (https://blacklivesmatter.com/resources). Specifically, mental health professionals can access and utilize the #BlackLivesMatter toolkits focused on healing justice and action, as well as the toolkit titled #TalkAboutTrayvon. Such resources can be a starting place to gain knowledge and develop a strategy for advocacy.
Limitations and Future Research
This study, although rich in details of the experiences of African American mothers, is not without limitations. Although attempts were made to secure African American mothers from varying sub-groups, the resulting sample yielded mainly educated women from mostly two-parent middle-class families, most of whom were from the Southern region of the United States. A more economically and educationally diverse sample of African American mothers might have yielded differences in experiences. For instance, given that poor communities of color are often over-policed (Alexander, 2010), African American mothers in lower socioeconomic brackets might have discussed direct contact with law enforcement and increased incidents of both community and state violence. Additionally, although many of the participants were married or partnered, the researchers did not explore how their spouses or partners played a role in their experience as African American mothers. Some participants mentioned the fathers of their sons and their perspectives; however, this relational aspect needs further inquiry to fully understand its essence. It was beyond the scope of this study to examine the experiences of African American fathers raising sons in the context of #BlackLivesMatter, yet this is certainly a worthy line of research that would augment the findings of this study.
Despite the lack of heterogeneity in this sample with regards to education and income, and focus on mothers to the exclusion of their spouses, partners, or co-parents, the design of the study provided rich and in-depth data regarding a relatively unexplored yet salient topic among a unique sample. Future research can extend the knowledge base regarding African American mothers by exploring the experiences of mothers who are raising daughters in the current context in which exposure to community and state violence occurs regularly through social media. Often, conversations regarding community and state violence, particularly when police use of excessive force is involved, focus on the experiences of African American boys and men. However, Crenshaw’s (1991) work on intersectionality as well as the #SayHerName movement (2015) reminds us that African American girls and women also are victims of community and state violence. Including mothers raising daughters into this line of research will help uncover the ways in which gender influences motherhood among African Americans when #BlackLivesMatter and #SayHerName intersect. Additionally, future research should include both homogenous and heterogenous focus groups of mothers to explore, compare, and contrast the experiences of mothers of color and White mothers in terms of parental stress, mental health, and physical health. Finally, future research should focus on identifying social determinants of health that counselors, physicians, and other helpers can use to address health disparities that may be exacerbated by ongoing psychological trauma.
Conclusion
The results of this qualitative study highlight the experiences of African American mothers—“crazy and brave” women—determined to protect and provide for their sons while also contending with a lingering fear for their safety within the current social context. State and community violence, now widely broadcasted in media, affect the psychological and physical well-being of these mothers and contribute to hypervigilance in their parenting. As mental health professionals that value the enhancement of human development and the promotion of social justice, counselors have a duty to provide culturally sensitive services to support this population so that they can take off their masks and experience the empathy that is lacking in many aspects of their lives. Additionally, this duty extends beyond the counseling room as counselors serve as social justice advocates in order to address the systemic barriers to mental health and wellness for members of the African American community.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Alexander, M. (2010). The new Jim Crow: Mass incarceration in the age of colorblindness. New York, NY: The
New Press.
American Counseling Association. (2014). 2014 ACA code of ethics. Retrieved from http://www.counseling.org/
Resources/aca-code-of-ethics.pdf
Berk, L. E. (2013). Child development (9th ed.). Boston, MA: Pearson.
Berry, J. O. & Jones, W. H. (1995). The Parental Stress Scale: Initial psychometric evidence. Journal of Social and Personal Relationships, 12, 463–472. doi:10.1177/0265407595123009
Black Lives Matter. (n.d.). Herstory. Retrieved from https://blacklivesmatter.com/about/herstory
Bor, J., Venkataramani, A. S., Williams, D. R., & Tsai, A. C. (2018). Police killings and their spillover effects on the mental health of black Americans: A population-based, quasi-experimental study. The Lancet, 392, 302–310. doi:10.1016/S0140-6736(18)31130-9
Cain, D. S., & Combs-Orme, T. (2005). Family structure effects on parenting stress and practices in the African American family. Journal of Sociology and Social Welfare, 32(2), 19–40.
Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35, 13–105. doi:10.1177/0011000006292033
CBS News. (2016). How Emmett Till’s brutal death “ignited a movement” in America. Retrieved from https://www.cbsnews.com/news/emmett-till-murder-mamie-mobley-america-civil-rights-movement-smithsonian-museum
Chang, Y., Fine, M. A., Ispa, J., Thornburg, K. R., Sharp, E., & Wolfenstein, M. (2004). Understanding parenting stress among young, low-income, African-American, first-time mothers. Early Education and Development, 15, 265–282. doi:10.1207/s15566935eed1503_2
Comstock, D. L., Hammer, T. R., Strentzsch, J., Cannon, K., Parsons, J., & Salazar, G., II (2008). Relational-cultural theory: A framework for bridging relational, multicultural, and social justice competencies. Journal of Counseling & Development, 86, 279–287. doi:10.1002/j.1556-6678.2008.tb00510.x
Conger, R. D. & Donnellan, M. B. (2007). An interactionist perspective on the socioeconomic context of human development. Annual Review of Psychology, 58, 175–199. doi:10.1146/annurev.psych.58.110405.085551
Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics. University of Chicago Legal Forum, 1989, 139–167.
Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43, 1241–1299.
Creswell, J. W. (2013). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). Thousand Oaks, CA: Sage.
Cross, D., Vance, L. A., Kim, Y. J., Ruchard, A. L., Fox, N., Jovanovic, T., & Bradley, B. (2018). Trauma exposure, PTSD, and parenting in a community sample of low-income, predominantly African American mothers and children. Psychological Trauma: Theory, Research, Practice, and Policy, 10, 327–335.
doi:10.1037/tra0000264
DePouw, C., & Matias, C. (2016). Critical race parenting: Understanding scholarship/activism in parenting our children. Educational Studies, 52, 237–259.
Drabold, W. (2016). Meet the mothers of the movement speaking at the Democratic Convention. Retrieved from
http://time.com/4423920/dnc-mothers-movement-speakers
Fulton, S. (2014). Trayvon Martin’s mom: “If they refuse to hear us, we will make them feel us.” Retrieved from http://time.com/3136685/travyon-sybrina-fulton-ferguson
Galovski, T. E., Peterson, Z. D., Beagley, M. C., Strasshofer, D. R., Held, P., & Fletcher, T. D. (2016). Exposure to violence during Ferguson protests: Mental health effects for law enforcement and community members. Journal of Traumatic Stress, 29, 283–292. doi:10.1002/jts.22105
Greer, T. M. (2011). Coping strategies as moderators of the relation between individual race-related stress and mental health symptoms for African American women. Psychology of Women Quarterly, 35, 215—226. doi:10.1177/0361684311399388
Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18, 59–82. doi:10.1177/1525822X05279903
Harris-Perry, M. (2014). A letter of sympathy to Michael Brown’s mother. Retrieved from http://www.msnbc.com/melissa-harris-perry/letter-sympathy-michael-browns-mother
Hays, D. G., & Wood, C. (2011). Infusing qualitative traditions in counseling research designs. Journal of Counseling & Development, 89, 288–295. doi:10.1002/j.1556-6678.2011.tb00091.x
Hunting, G. (2014). Intersectionality-informed qualitative research: A primer. Vancouver, British Columbia: The Institute for Intersectionality Research and Policy.
Kennedy, A. C., Bybee, D., & Greeson, M. R. (2014). Examining cumulative victimization, community violence exposure, and stigma as contributors to PTSD symptoms among high-risk young women. American Journal of Orthopsychiatry, 84, 284–294. doi:10.1037/ort0000001
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage.
Marshall, C., & Rossman, G. B. (2006). Designing qualitative research (4th ed.). Thousand Oaks, CA: Sage.
Matjasko, J. L., & Feldman, A. F. (2006). Bringing work home: The emotional experiences of mothers and fathers. Journal of Family Psychology, 20, 47–55. doi:10.1037/0893-3200.20.1.47
Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage.
Onwuegbuzie, A. J., & Leech, N. L. (2007). A call for qualitative power analyses. Quality & Quantity, 41, 105–121. doi:10.1007/s11135-005-1098-1
Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 59, 1–9.
doi:10.1037/a0026208
Premkumar, A., Nseyo, O., & Jackson, A. V. (2017). Connecting police violence with reproductive health. Obstetrics and Gynecology, 129, 153–156. doi:10.1097/AOG.0000000000001731
Raphael, J. L., Zhang, Y., Liu, H., & Giardino, A. P. (2010). Parenting stress in US families: Implications for paediatric healthcare utilization. Child: Care, Health and Development, 36, 216–224.
doi:10.1111/j.1365-2214.2009.01052.x
#SayHerName Movement. (2015). #SayHerName: Resisting police brutality against Black women. Retrieved from http://aapf.org/sayhernamereport
Sebastian, M. (2016). Who are the “Mothers of the Movement” speaking at the Democratic National Convention? Retrieved from https://www.elle.com/culture/career-politics/news/a38111/who-are-mothers-of-the-movement-dnc
Stewart, F. R. (2017). The rhetoric of shared grief: An analysis of letters to the family of Michael Brown. Journal of Black Studies, 48, 355–372. doi:10.1177/0021934717696790
Szymanski, D. M., & Owens, G. P. (2009). Group-level coping as a moderator between heterosexism and sexism and psychological distress in sexual minority women. Psychology of Women Quarterly, 33, 197–205. doi:10.1111/j.1471-6402.2009.01489.x
Umberson, D. (2017). Black deaths matter: Race, relationship loss, and effects on survivors. Journal of Health and Social Behavior, 58, 405–420. doi:10.1177/0022146517739317
Richelle Joe, NCC, is an assistant professor at the University of Central Florida. M. Ann Shillingford-Butler, NCC, is an associate professor at the University of Central Florida. Seungbin Oh is an assistant professor at Merrimack College. Correspondence can be addressed to Richelle Joe, P.O. Box 161250, Orlando, FL 32816-1250, jacqueline.joe@ucf.edu.
Nov 29, 2017 | Volume 7 - Issue 4
Angelica M. Tello, Nancy E. Castellon, Alejandra Aguilar, Cheryl B. Sawyer
The United States has recently seen a significant increase in the number of unaccompanied minors from the Northern Triangle of Central America (i.e., El Salvador, Honduras, and Guatemala). These children and youth are refugees fleeing extreme poverty and gang violence. This study examined the narratives of 16 refugees from the Northern Triangle who arrived in the United States as unaccompanied minors. In particular, the purpose of this study was to gain awareness of the journey experienced by unaccompanied refugee minors from their countries of origin to the United States. Thematic analysis was used to analyze the participants’ narratives, and three primary themes emerged: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States. Implications for counselors and areas for future research are discussed.
Keywords: unaccompanied minors, refugees, Central America, Northern Triangle, mental health
Displaced refugees are a worldwide crisis. The United Nations High Commissioner for Refugees (2015) reported there are 21.3 million refugees worldwide, and half are under the age of 18. Although much attention is given to the refugee crisis in Europe and the Middle East, the United States has recently seen a significant increase in unaccompanied refugee minors from the Northern Triangle of Central America (Sawyer & Márquez, 2017). These are children and youth from Honduras, Guatemala, and El Salvador who are traveling alone and crossing the Mexican border into the United States without legal authorization (Chen & Gill, 2015; Sawyer & Márquez, 2017; Stinchcomb & Hershberg, 2014).
Unaccompanied minors who are apprehended by immigration officials from the Department of Homeland Security (DHS) are transferred to the Office of Refugee Resettlement (ORR) for care (ORR, 2016). ORR (2016) reported that in their first nine years, they annually served an average of 7,000 to 8,000 unaccompanied minors. In 2012, ORR observed their first increase in numbers; services were provided to 13,625 unaccompanied children and youth (ORR, 2016). By 2014, there was a drastic increase in the number of unaccompanied minors arriving to the United States (Androff, 2016; DHS, 2016; ORR, 2016). DHS reported that 68,541 unaccompanied children and youth from Central America were apprehended at the southern border (DHS, 2016). There also was a 117% increase in the number of unaccompanied children under the age of 12 (Krogstad, Gonzalez-Barrera, & Lopez, 2014).
Although there has been a decrease in the number of unaccompanied minors entering the United States in the last few years, the numbers are still quite large. In 2016, 59,692 unaccompanied children and youth were apprehended, and 33% were female (ORR, 2016). Furthermore, the highest percentage of children were from Guatemala at 40%, followed by El Salvador and Honduras with 34% and 21%, respectively (ORR, 2016).
Unfortunately, because of recent anti-immigration rhetoric in the United States, the general public is often misinformed of the experiences of unaccompanied minors (Androff, 2016). In 2014, at the height of the surge of unaccompanied minors, various anti-immigration protests occurred in the United States against children and youth from Central America (Androff, 2016; Knake, 2014). In a protest organized in Michigan by the Michiganders for Immigration Control and Enforcement, some protesters carried rifles and handguns along with signs that read “seal the border,” “it’s law—deport,” and “no illegals” (Knake, 2014, para. 12). A major misconception is that unaccompanied minors are immigrants. However, the unaccompanied children and youth from the Northern Triangle of Central America are refugees fleeing impoverished living conditions, extreme violence from gangs and organized crime, and political instability (Androff, 2016; Chishti & Hipsman, 2015; Jani, Underwood, & Ranweiler, 2016; Sawyer & Márquez, 2017). DHS Secretary Jeh Johnson reported that over the last 15 years “far fewer Mexicans and single adults are attempting to cross the border without authorization, but more families and unaccompanied children are fleeing poverty and violence in Central America” (DHS, 2016, para. 1).
Reasons for the Increase of Unaccompanied Minors
The poverty and violence experienced by those living in the Northern Triangle of Central America have been well documented (Chishti & Hipsman, 2015; Gonzalez-Barrera et al., 2014; Jani et al., 2016; Sawyer & Márquez, 2017; Women’s Refugee Commission, 2012). Impoverished living conditions and gang violence are the major factors leading unaccompanied minors to leave Central America. Even though the journey to the United States is filled with grave danger, children are fleeing Central America because of their dire living situations.
Poverty and the Lack of Economic Opportunities
Societal inequalities and natural disasters have negatively impacted this region (International Organization for Migration [IOM], 2016; Seelke, 2016). These inequalities have led those living in the Northern Triangle to experience high rates of poverty and limited economic opportunities. Since 2012, El Salvador, Guatemala, and Honduras have been impacted by prolonged drought (IOM, 2016). This has caused immense food insecurity and has negatively affected agricultural labor. For instance, nearly 50% of the Guatemalan population has experienced chronic undernutrition (IOM, 2016). Furthermore, over half of the population in Honduras and Guatemala live in poverty: 63% and 59%, respectively (Seelke, 2016), and 40% in El Salvador (Padgett, 2014). The Northern Triangle also has high rates of youth unemployment. In El Salvador and Honduras, over 25% of youth ages 15–24 have never worked or studied (De Hoyos, Rogers, & Székely, 2016).
Violence by Gangs and Organized Crime
According to the Council on Foreign Relations, “El Salvador, Guatemala, and Honduras consistently rank among the most violent countries in the world” (Renwick, 2016, para. 4). In 2015, El Salvador’s homicide rate was the highest in the world, with 105 murders per 100,000 inhabitants (Watts, 2015). Moreover, this makes El Salvador almost 20 times more deadly than the United States (Watts, 2015). It is important to note that from 2011 to 2015, San Pedro Sula, Honduras, was identified as the most violent city in the world outside a war zone (O’Connor, 2012). From 2005 to 2010, the murder rate in Honduras more than doubled (United Nations Office on Drugs and Crime, 2011). Guatemala City also has consistently ranked as one of the most violent cities. The U.S. Department of State’s Overseas Security Advisory Council (2016) stated that “Guatemala’s homicide rate is one of the highest in the Western Hemisphere,” with 91 murders per week in 2015 (para. 2).
The high murder rates in the Northern Triangle of Central America are attributed to the maras, or gangs, in that region (Chishti & Hipsman, 2015; Jani et al., 2016; Sawyer & Márquez, 2017; Watts, 2015). The violence and murders are because of the rivalry of two prominent gangs: the Mara Salvatrucha, also known as MS-13, and Barrio 18 (Sawyer & Márquez, 2017; Seelke, 2016; Watts, 2015). These gangs were able to flourish in the Northern Triangle because of weak government and political instability in the region (Sawyer & Márquez, 2017). From the 1980s into the early 1990s, there was a deadly civil war in El Salvador between the government and the Martí National Liberation Front, a Salvadorian political party (Sawyer & Márquez, 2017). From 1960 to 1996, Guatemala suffered from a 36-year civil war between civilian farmers who lost land and voting rights and government military forces (Sawyer & Márquez, 2017). Furthermore, Honduras experienced a military coup in 2009, which led the government to suspend freedom of assembly and the press and authorize excessive force to silence opposition (Sawyer & Márquez, 2017). As the countries began to rebuild after these periods of political unrest, gangs in this region were able to go unchecked.
Gangs in Central America were able to gain control in part because of the drug demands of the United States. These gangs assist in the transportation of cocaine and marijuana moving from South America into Mexico, and eventually the United States (Sawyer & Márquez, 2017; Seelke, 2016; Watts, 2015). However, the Central American gangs are not the major narco-cartel suppliers, so they have relied on robbery, extortion, kidnapping, human trafficking, and weapons smuggling for additional sources of income (Seelke, 2016; Watts, 2015). The extortions have impacted residents, bus and taxi drivers, and general business owners (Seelke, 2016; Watts, 2015). For instance, in the El Salvadorian city of San Salvador, gangs demand residents pay “war taxes,” and those that do not pay face harassment and violence (Ribando, 2007, p. 4).
The gangs actively target children and youth as young as 7 or 8 years old for recruitment (Sawyer & Márquez, 2017). Moreover, the gangs use coercive and violent means, such as kidnapping, extortion, and murder, to force families to “give up their children” (Jani et al., 2016, p. 1196). In El Salvador, gangs have even targeted children at schools, resulting in low school attendance rates (Women’s Refugee Commission, 2012). On the other end, some youth become susceptible to gang recruitment because of high unemployment and absence of family influences (Farah, 2016). Nevertheless, the violence and intimidation perpetuated by gangs are major push factors leading children and youth to flee Central America. The exposure to violence also can have an impact on the mental health of unaccompanied minors.
Mental Health Needs of Unaccompanied Refugees
Although there is a limited understanding of the mental health needs of unaccompanied minors from the Northern Triangle of Central America, researchers have documented the common mental health needs of refugees. Because many refugees have been exposed to traumatic events and violence in their countries of origin, they experience higher rates of mental health issues, such as post-traumatic stress disorder (PTSD), depression, and emotional and behavioral problems (Bronstein & Montgomery, 2011; Karaman & Ricard, 2016; Kirmayer et al., 2011). Mental health needs do not solely stem from the trauma exposure experienced by refugees pre-migration. Many refugees also experience trauma and uncertainties during their migration and post-migration resettlement that negatively impact their mental health (Bronstein & Montgomery, 2011; Karaman & Ricard, 2016; Kirmayer et al., 2011).
According to a recent study conducted by Keller, Joscelyne, Granski, and Rosenfeld (2017), Central American refugees from El Salvador, Honduras, and Guatemala have “significant mental health symptoms” because of the violence they experienced (p. 1). Of their sample of 234 participants, 204 experienced trauma in their countries of origin, 182 fled because of violence concerns, and 166 were afraid to return home. Moreover, rates of depression and PTSD were high among those from the Northern Triangle: 32% reported clinically significant PTSD symptoms and 24% had major depressive disorder symptoms (Keller et al., 2017). Similar findings were echoed in a study that examined the mental health needs of Guatemalan refugees living in Mexico (Sabin, Lopes Cardozo, Nackerud, Kaiser, & Varese, 2003). The researchers surveyed 170 participants, and all reported at least one traumatic event, with a total of 1,230 reported traumatic events (e.g., being close to death, friend or family member massacred, witnessing the disappearance of others; Sabin et al., 2003). From these participants, 11.8% met symptom criteria for PTSD, 54.4% had anxiety symptoms, and 38.8% revealed depression symptoms (Sabin et al., 2003).
Further research is needed on the mental health needs of unaccompanied minors from the Northern Triangle of Central America. The purpose of this study was to gain awareness of the journey experienced by unaccompanied minors from their countries of origin to the United States and to provide implications for counselors. Therefore, the following research question guided the study: What are the experiences of unaccompanied refugee minors from the Northern Triangle of Central America?
Method
Thematic analysis, a qualitative methodological approach, was utilized because the researchers were analyzing written narratives. Thematic analysis, unlike content analysis, provides a rich and detailed description of the data (Vaismoradi, Turunen, & Bondas, 2013). This research study was approved by the researchers’ institutional review board.
Participants
The researchers analyzed the narratives of 16 participants. All the participants entered the United States as unaccompanied minors from the Northern Triangle of Central America (i.e., El Salvador, Honduras, and Guatemala) and were receiving assistance through a shelter in the Southern region of the United States. Part of the assistance included counseling services offered by a counseling graduate program affiliated with the researchers. After gaining signed consent forms, the participants and their appointed legal guardians received individual counseling sessions in Spanish with bilingual counselors-in-training (CITs). Three of the participants were female, and 13 were male. Ten of the participants were from Honduras, three were from Guatemala, and three were from El Salvador. Participants’ ages ranged from 10 to 23. Although some of the participants were over 18 years of age at the time of the study, they arrived in the United States as unaccompanied minors.
Data Collection
The data was collected during the counseling process. The CITs involved had at least one semester of supervised counseling experience. They also had completed all foundational counseling courses in their degree plan, including counseling theories, multicultural counseling, assessment, diagnosis, human growth and development, crisis intervention, counseling skills, and group counseling. At the time of the study, the CITs were enrolled in a bilingual counseling course and received information on the counseling needs of unaccompanied refugee minors.
Each CIT was assigned a participant and completed three to 18 hours of individual counseling sessions. The hours varied depending on the participants’ availability. Because the participants were exposed to violence in their countries of origin and the journey to the United States, CITs utilized basic relaxation skills, trauma-focused cognitive behavioral therapy (TF-CBT), and expressive counseling techniques to help the participants process their experiences. Upon conclusion of the counseling sessions, each participant organized a digital storybook that illustrated and discussed their journey to the United States. The storybooks were created on iPads using Microsoft PowerPoint. The participants received assistance from their CITs on utilizing the iPad and writing the content for each page of their book. The books ranged from five to 26 pages. After eliminating all identifying information, the content of the books was provided to the researchers by the CITs. The content was then translated from Spanish to English, and two external auditors provided language translation verification.
Data Analysis
The data were analyzed using the thematic analysis approach outlined by Braun and Clarke (2006). First, the researchers familiarized themselves with the data by reading and re-reading each participant’s book content. Key ideas were documented during this time. Next, a systematic approach was taken in reviewing the data and identifying codes. In particular, a “data-driven” approach was used to code instead of a “theory-driven” approach (Braun & Clarke, 2006, p. 88). These codes were then grouped into potential themes based on shared meanings. The researchers also reviewed and discussed the themes to ensure they represented the data. This process allowed for the refining of each specific theme. External auditors then reviewed the themes and reported that the themes reflected the participants’ experiences. The participants discussed their journey from their countries of origin to the United States. Therefore, the themes reflect what occurred on their journey. Based on these themes, the researchers provide implications for counselors and discuss mental health issues.
Results
Based on the analysis of the participants’ narratives, the researchers identified three primary themes and 11 subthemes. The primary themes were: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States. Each theme is described in the following section. Pseudonyms were selected for each participant to protect their privacy.
Reasons for Leaving Central America
All the participants discussed factors that contributed to them fleeing their countries of origin. Three subthemes fell under the primary theme of what led the participants to leave Central America: (a) to financially help family, (b) to escape gang violence and death, and (c) powerlessness. It is important to note that these subthemes are closely related. The gangs in the Northern Triangle of Central America were a result of the extreme poverty in that region, and they also contributed to the poverty experienced by the participants.
Financially help family. Many of the participants experienced extreme poverty in their home countries. Enrique shared how he grew up in a “house made out of sticks, mud, and rocks” and how his family “melted fat in order to eat.” When he was 10 years old, his father was killed by a gang, and he stopped attending school to provide for his family. He left for the United States with the support of his mother because it was difficult to find a job and the country’s economy was unstable because of the gangs. Many of the participants echoed these sentiments. For instance, Federico also shared that “poverty, delinquency, and lack of work opportunities” led him to leave his native country for “a more promising future for myself and my family.”
Escape violence and death. All the participants fled their home countries in order to escape violence and death. Federico provided a detailed account of how the maras, or gangs, in his native country recruited children as new members. If someone did not join, the gang members would kidnap, rape, or kill his or her family members. This led Federico and many of the participants to flee their countries; they felt there was no other option to escape the violence.
Some participants left their native countries because gang members threatened to kill them. Brenda lost her parents because of gang violence and was living with her aunt and uncle. Brenda fled to the United States shortly after this incident: “My aunt received a phone call from somebody who said that my sister and I were easy targets. . . . And if they were not paid a certain amount, we [participant and her sister] would be hurt.”
Powerlessness. Another subtheme that emerged was powerlessness. Some of the participants were homeless because of the extreme poverty and violence. Additionally, they felt alone and had no family ties left in their home countries. These participants felt powerlessness regarding what occurred in their lives and fled to the United States to gain a sense of control. Armando shared feeling powerless after his mother died from a heart attack when he was 14 years old. Afterward, he lived with his brothers for 2 years, but they did not support him. Armando’s friend then encouraged him to flee to the United States because he was on his own.
Journey to the United States
In their narrative books, the participants discussed what occurred on their journeys to the United States. The subthemes that fell under this primary theme were: (a) mode of journey, (b) physical pain, (c) emotional pain, and (d) help from others.
Mode of journey. Participants either arrived by riding above trains or through the assistance of a smuggler, also known as a coyote. Carlos tried multiple times to come to the United States and primarily used the train. His first attempt was at 6 years old, but he was unable to complete the journey. The second time Carlos fled Central America, he “came aboard the train of death.” The train was often referred to by participants as la bestia, or the beast. Several participants shared these experiences. For instance, Enrique made three attempts to leave Central America starting at 11 years old. His journey took him 8 months to arrive in the United States. Other participants arrived in the United States through smugglers. Cristobal described how his parents saved money so they could pay a coyote to bring him to the United States.
Physical pain. The participants provided various accounts of physical and emotional trauma experienced on their journey to the United States. Several of the participants reported being beaten and robbed in Mexico when their trains would stop at various points. To find food, the refugees had to get off the train. Federico discussed how traveling alone led one to be vulnerable to “food, water, and clothes predators.”
Some participants described not knowing what to expect on their path to the United States; they were not prepared for what lay ahead while on the train or by foot. Federico wrote: “We knew nothing about the journey, knew no landmarks, and knew nothing about the path that could help us plan ahead.” Damian wrote about the freezing temperatures he was not prepared for when the train reached mountainous terrain. He was traveling with two other boys, and they were only wearing t-shirts and pants. He described how he felt immense pain from the freezing weather and worried that he was “dying from the cold.” Damian felt fortunate that he was traveling with someone who told him they needed to take off their clothes and use their body heat to keep warm.
Other participants provided accounts of being physically injured on their journey because of days of walking in desert terrain. Brenda recalled the injuries and pain caused to her feet: “It took us 8 days to get to our stopping point. I remember that my shoes had peeled the soles of my feet, and my toenails had fallen off.” Feet being severely damaged from walking was a common experience shared by the participants.
Fernando began his journey at 10 years old and recounted the injuries he received from the train and walking nonstop for 2 days as he approached the Mexico–United States boarder: “My arms were bandaged from having been hurt on the train. . . . I saw the body of a man floating in the river. I wondered if it was the body of my father.” Fernando’s accounts illustrate the nature of the physical and emotional pain the participants experienced. Not only was Fernando physically hurt on his journey, but he also carried the emotional or psychological wounds of witnessing death at a young age. In his book, Fernando also wrote about seeing a man’s body being dismembered after accidentally falling from the train.
Emotional pain. All the participants were exposed to and witnessed trauma on their journey to the United States. They were exposed to physical and sexual assaults and death. For instance, riding above the train was very dangerous. Participants provided accounts of people being sucked under the train as they tried to jump on. Enrique wrote about seeing a girl die trying to get on the train. Federico stated that the following events impacted him the most on his journey: “(I) witnessed a person being shot to death, the raping of women while family members were forced to witness this, witnessing a person being cut to pieces by the train, and seeing pieces of human bodies alongside the railroads.” These were not isolated events; all the participants reported at least one such traumatic situation.
Damian wrote how he “felt frustrated and powerless” after seeing a girl being raped by a gang of three or four men; the girl’s brother was forced to watch the sexual assault. He met the girl and her brother a few days before the sexual assault occurred. Damian was told by his cousin not to intervene or confront the rapists because he would most likely be killed or severely assaulted by the gang. Many of the participants, like Damian, noted that these memories were reoccurring, and how they often think about those whom they saw injured and sexually assaulted. Damian wrote how he wants to find the girl who was raped and explain to her why he did not intervene and that he wants to apologize. In his book, Damian listed her name and the city she was planning to arrive to in the United States.
Help from others. The last subtheme that emerged from the participants’ narratives was receiving help from others. Even though the participants experienced physical and emotional trauma on their journey to the United States, they met individuals along the way that provided assistance. Many of the participants reported struggling to find food. Ismael wrote: “I also remember good people throwing food at us because they knew we were hungry.” Damian shared how he met a “good-hearted lady” that gave him advice on evading possible harm. She told Damian to be careful about motorcycles because they were involved with “kidnapping migrants and asking their families for ransom.” Although this information caused “more real fear” in Damian, it helped him on his journey. There were several accounts of priests in Mexico helping refugees find local shelter. Enrique shared that he received help from a priest who took him to a “house of immigrants” to receive food, clothes, and shelter. These instances of support helped the refugee children and youth continue on their journey.
Life in the United States
The last primary theme related to the participants’ life in the United States. Four subthemes emerged from the participants’ narratives: (a) faith, (b) worries about the future, (c) help from others, and (d) view of self after the journey.
Faith. Some of the participants discussed how they felt God “guided” them on their journey to the United States. When they faced obstacles and harm, God protected them and provided guidance. As a result, they felt God would be present in their life in the United States. Even though they are continuing to face challenges in the United States (e.g., court hearings, financial instability), they believed God would continue to provide support. In her book, Delmy wrote that “although there might be darkness in life, there is light that always breaks through the darkness.” She then stated that her faith provides her the “light” to keep moving forward in the United States.
Worries about the future. The refugee children and young adults in the study described various worries about their future. Some participants shared worries about providing for their family. Robert echoed these sentiments; he had two jobs to help his family back home. Other participants were worried about their family’s safety in Central America. Damian described how he is worried because his “mother is sad.” She even told him that “she doesn’t want to live anymore” because of the dire situation in Central America. Damian also was worried about the safety of his younger sister.
There were worries expressed about the participants’ safety in the United States. Delmy expressed feeling alone at the detention center and “fears” that people want to harm her. Moreover, several participants expressed worries about their immigration status in the United States and being judged by American society. Jesus stated: “I hope that one day I can be accepted by the American society. I can only pray that I am not judged too harshly. I plan on continuing to help my family to have a better life.” Tomas, like many of the participants, was waiting on his court hearing. He described the uncertainty and worries of his future: “My future is uncertain. . . . I will either be deported back to my country where there is a high possibility that I can be killed, or my immigration status will become legalized in the near future.” For those that fled gang violence, being sent back to their countries of origin could be a death sentence. For Carlos, who recently gained legal status, there was worry about discrimination he might face in the United States: “Some people judge me without knowing me, even more so in this country where there is so much discrimination against immigrants. And even though I am legal, it does not mean that other people will not judge me.”
Help from others. Participants noted receiving help from individuals in the United States. The help they received provided them with hope and guidance to keep moving forward in a positive direction. In his book, Armando expressed how he allowed himself to be picked up by immigration authorities. He felt alone and did not know how he was going to survive in the United States. Armando shared that once he was detained, he received help from his assigned lawyer. She gave Armando hope that he could stay in the United States, attend school, and have a positive future. Now, Armando wants to give back to his community and help other unaccompanied minors from Central America. Damian expressed similar sentiments; he wants to help others because of the support he received from the director of a children’s shelter. The director has become a father figure to Damian and has helped him realize that he has a future.
View of self after the journey. The participants’ views of themselves after their journey was another subtheme that emerged from the participants’ narratives. For some participants, they felt their life was going nowhere—there was no hope. Tomas expressed these sentiments: “My American dream has become my nightmare. My journey here was not pleasant plus I feel helpless here because I cannot help my family in Central America. . . . I feel my life has no meaning.” Not only was Tomas’s journey filled with trauma and pain, his life in the United States was uncertain. Furthermore, he was separated from his family and unable to help them financially or provide for their safety. Other participants viewed themselves as “survivors.” Carlos finished his book with the following: “This book does not show all the pain and sacrifice that I have endured, but it is a reminder that I am a survivor.”
Discussion
This study examined the narratives of 16 refugees from El Salvador, Honduras, and Guatemala who arrived to the United States as unaccompanied minors. The data set was gathered to answer the research question: What are the experiences of unaccompanied refugee minors from the Northern Triangle of Central America? From the participants’ narratives, three primary themes emerged: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States.
There were three prominent reasons that led participants to flee their home countries in Central America. Some participants described living in poverty and leaving for the United States to financially help the family. Also, all participants discussed fleeing to escape gang violence and death. Previous literature on unaccompanied refugees from the Northern Triangle has discussed how poverty (Gonzalez-Barrera et al., 2014; IOM, 2016) and gang violence (Jani et al., 2016; Sawyer & Márquez, 2017; Seelke, 2016) are major push factors. However, participants in this study also reported feelings of powerlessness that led them to leave their home countries. Participants described feeling they did not have control of what was occurring in their lives and fleeing to the United States was a way to take hold of their future. These pre-migration worries and stressors could impact the mental health of the participants. Unaccompanied refugee minors have more traumatic stress reactions than accompanied children and non-immigrants (Bean, Derluyn, Eurelings-Bontekoe, Broekaert, & Spinhoven, 2007).
This study also provided some insight into the experiences of unaccompanied refugee minors on their journey to the United States. The participants described their mode of journey, which fell into two categories: using a coyote, or smuggler, and riding above trains. These findings were consistent with what has been documented in the literature (Sawyer & Márquez, 2017; Uehling, 2008) regarding unaccompanied refugees from Central America. Previous literature (Keller et al., 2017; Sawyer & Márquez, 2017) has focused on the living conditions of refugee minors in their home countries, which represent the push factor present in their lives in El Salvador, Honduras, and Guatemala. The participants in this research study shared the physical and emotional pain that was part of the journey to the United States. They provided detailed accounts of how they were physically assaulted, faced various injuries to their bodies because of long days of walking, and lacked the proper clothing to endure the various terrains they encountered. Furthermore, the participants also shared the emotional pain they experienced on their journey: reoccurring images from witnessing physical and sexual assaults and seeing dead bodies. These types of physical and emotional pain place unaccompanied refugee minors at greater risk of mental health problems. The exposure to trauma and stressors can lead refugees to develop depressive and anxiety disorders including PTSD (Keller et al., 2017; Sabin et al., 2003; Vervliet at al., 2014). For minors, mental health issues can significantly impair their functioning (e.g., academics; Fox, Burns, Popovich, Belknap, & Frank-Stromborg, 2004).
In the literature on unaccompanied refugees from the Northern Triangle, there was limited understanding of their experience once they arrived in the United States. The participants in this study provided some insight into these experiences. Faith was a prominent theme that emerged and has not been discussed in the literature. For many of the participants, their faith and religious views were sources of strength as they transitioned to life in the United States. Participants also gained a sense of empowerment from the help they received from various sources in the United States. Emotional support from lawyers or mentors in the community gave the participants hope to continue moving forward in a positive direction. However, many of the participants shared worries about their future. These worries were about their family members who were left back at home, their safety in the United States, and the uncertainty of their legal status. Many of the participants also were aware of the discrimination they would face in the United States.
Discrimination and prejudice have been documented as post-migration stressors for immigrants in the United States (Pumariega, Rothe, & Pumariega, 2005). Discrimination can have a negative impact on the mental health of refugees (Montgomery & Foldspang, 2008). Those who experience discrimination may exhibit stress and depressive symptoms (Stuber, Galea, Ahern, Blaney, & Fuller, 2003). The participants wondered whether discrimination would impact their ability to stay in the United States or cause them to be deported. For these participants, deportation meant being sent back to a death sentence. All of these worries and uncertainties about their future led some participants to feel they had no hope for their futures.
Along with the exposure to trauma experienced by unaccompanied minors pre-migration, they experience additional stressors post-migration in the United States. In a study conducted with unaccompanied refugee minors in Europe, there were high rates of anxiety, depression, and PTSD symptoms (Vervliet et al., 2014). In particular, high scores were rated (self-report measures: Hopkins Symptoms Checklist-37A, Stressful Life Events, Reactions of Adolescents to Traumatic Stress, and Harvard Trauma Questionnaire) for these symptoms shortly after the unaccompanied minors arrived at their host countries (Vervliet et al., 2014). Their findings dispute previous research that suggests that there is a “honeymoon” phase experienced after arrival in the host country (Tousignant, 1992; Ward, Okura, Kennedy, & Kojima, 1998). This study helps shed some light into the additional stressors experienced by unaccompanied refugee minors post-migration: worries about their future such as safety, immigration status, and being judged. Constant uncertainty about their future, coupled with the exposure of trauma in their past, might increase the anxiety, depression, and PTSD symptoms experienced by unaccompanied refugees. Obviously, counselors can play an important role in addressing the mental health needs of unaccompanied refugee minors.
Implications for Counselors
Unaccompanied refugees from Central America experience various forms of trauma in their countries of origin and on the journey to the United States (Keller et al., 2017; Sawyer & Márquez, 2017). As a result, these children and adolescents are at risk of developing PTSD and major depressive disorder symptoms (Keller et al., 2017; Sawyer & Márquez, 2017). Therefore, it is crucial that counselors working with unaccompanied refugees be informed of trauma counseling theories and interventions such as trauma-informed care (Substance Abuse and Mental Health Services Administration, 2014).
Additionally, counselors must practice multiculturally competent counseling services with this population and create a safe space for clients to process their trauma (Sawyer & Márquez, 2017). Building rapport is crucial when counseling refugees. Clients might be anxious about sharing personal information because of past experiences of mistrust (Tribe, 2002). Moreover, unaccompanied refugee minors might have culture-bound expressions of mental health symptoms (Pumariega et al., 2005). This means counselors must have an awareness of their client’s cultural upbringing. Counselors can work with “cultural consultants” who have connections with refugee communities and can assist in facilitating accurate mental health assessments (Pumariega et al., 2005, p. 591). Culturally competent counselors also need to be aware of factors that can affect the therapeutic relationship such as stigma, location, language barriers, and documentation (Pumariega et al., 2005).
Incorporating the client’s cultural values in session can assist refugees in “maintaining their equilibrium” (Tribe, 2002, p. 243). For many refugees, their sense of identity may have been threatened in their countries of origin (Tribe, 2002). For the participants in this study, arriving in the United States also meant encountering additional stressors to their sense of identity. For instance, many of the participants worried about their safety in the United States, immigration status, and judgments and discrimination from others. This study provides insight into cultural values that counselors can incorporate to help unaccompanied minors find some personal balance in the United States. Some participants shared how their faith and helping others brought personal meaning and hope for the future. Other participants held to the notion that they were survivors and that they have the skills to face struggles they will encounter in the future.
It is important for counselors working with unaccompanied refugees to understand the impact of vicarious trauma and the importance of self-care. The process of listening to the stories of refugees who have experienced trauma can in itself be very painful and cause the counselor to experience vicarious trauma. Before a counselor can begin to help a refugee client to open up about painful experiences, the counselor must consider: “Do I have the skills needed to help the client contend with the intense emotions that arise in the counseling process? Do I have the debriefing resources necessary to help myself contend with conflicting emotions?”
Although the CITs in this project had considerable experience working with refugee children as teachers and were intensely prepped for the possibility of hearing their clients discuss graphic content, they still related that the counseling process was emotionally stressful and draining. In order to help the CITs address any vicarious trauma they may have experienced from counseling unaccompanied refugees, they were debriefed after every session by their site supervisors. Many of the CITs involved in this process reported that by discussing their sessions with supervisors and with one another, they felt better able to deal with what they heard. Therefore, counselors providing services to unaccompanied refugees should regularly meet for individual or group supervision to debrief. It is important for counselors to understand the characteristics of vicarious trauma, such as cognitive distortions and changes in core beliefs (Bell, Kulkarni, & Dalton, 2003), intrusive thoughts or nightmares (Hernandez-Wolfe, Killian, Engstrom, & Gangsei, 2015), and decreased self-efficacy (Sartor, 2016). Clinical supervisors can play an important role in helping counselors to recognize and decrease symptoms of vicarious trauma (Lonn & Haiyasoso, 2016).
Engaging in self-care activities can help counselors who are providing services to clients who have experienced trauma (Lonn & Haiyasoso, 2016; Williams, Helm, & Clemens, 2012). Counselors can develop a wellness plan to help maintain self-care (Williams et al., 2012), such as participating in “spiritual or religious renewal” (e.g., prayer, meditation, yoga) or spending time in nature (e.g, camping, walking, hiking; Lonn & Haiyasoso, 2016, p. 4). Self-care activities also can include connecting with other counselors who provide services to unaccompanied refugees.
Limitations and Future Research
There were four limitations in this study. First, the study was comprised of more male than female participants. However, the sample is reflective of the population of unaccompanied minors who enter the United States in that males are more likely to enter the United States unauthorized than females (ORR, 2016). Second, the participants were asked to document their experiences in a digital storybook with the assistance of their CIT. The structure of the books could have limited what the participants shared about their experiences. Third, the digital storybooks were created after participants completed counseling. Participant reports could have been impacted by counseling. Lastly, as a result of the researchers utilizing a qualitative methodology, the findings have limited generalizability. Nevertheless, there were participants representing all three countries (i.e., El Salvador, Honduras, and Guatemala), which helps support limited transferability of the findings (Yardley, 2008).
The findings and limitations of this study provide areas for future research. The qualitative nature of the study and the findings around the emotional pain experienced by the participants opens up opportunities for conducting quantitative studies. This includes assessing if there are trauma-related diagnoses or depression and the degree to which it is experienced by unaccompanied refugees from the Northern Triangle. Moreover, the effectiveness of particular trauma-focused therapies with this population is an area that needs further exploration. For instance, TF-CBT is considered an evidence-based treatment approach with children and adolescents who have experienced trauma (Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011; Silverman et al., 2008). However, there is limited understanding of TF-CBT’s effectiveness with unaccompanied refugees from Central America. Also, examining culturally competent strategies of implementing TF-CBT with this population is warranted.
Conclusion
The treacherous journey unaccompanied minors must undertake to arrive in the United States is not a deterring factor. Secretary Jeh Johnson from the United States DHS reported: “Border security alone cannot overcome the powerful push factors of poverty and violence that exist in Central America. Walls alone cannot prevent illegal migration” (DHS, 2016, para. 4). Even though these children and adolescents walk thousands of miles and face hostile situations on their journey to the United States, they choose this path instead of the alternative, which for many, if they stay in their home country, is certain death (United Nations Children’s Fund, 2016; Women’s Refugee Commission, 2012). Ultimately, counselors and other helping professionals must consider the instinctive nature of self-preservation, especially in children. Child and adolescent refugees will continue to come to the United States seeking food, shelter, and asylum until their home situation becomes bearable. Until then, counselors and those supporting unaccompanied minors must understand the strengths, stresses, and struggles of refugees to develop effective practices for helping these children to be successful in their receiving country.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Androff, D. (2016). The human rights of unaccompanied minors in the USA from Central America. Journal of Human Rights and Social Work, 1(2), 71–77. doi:10.1007/s41134-016-0011-2
Bean, T., Derluyn, I., Eurelings-Bontekoe, E., Broekaert, E., & Spinhoven, P. (2007). Comparing psychological distress, traumatic stress reactions, and experiences of unaccompanied refugee minors with experiences of adolescents accompanied by parents. Journal of Nervous and Mental Disease, 195, 288–297. doi:10.1097/01.nmd.0000243751.49499.93
Bell, H., Kulkarni, S., & Dalton, L. (2003). Organizational prevention of vicarious trauma. Families in Society: The Journal of Contemporary Human Services, 84, 463–470. doi:10.1606/1044-3894.131
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101.
Bronstein, I., & Montgomery, P. (2011). Psychological distress in refugee children: A systematic review. Clinical Child and Family Psychology Review, 14, 44–56. doi:10.1007/s10567-010-0081-0
Chen, A., & Gill, J. (2015). Unaccompanied children and the U.S. immigration system: Challenges and reforms. Journal of International Affairs, 68, 115–133.
Chishti, M., & Hipsman, F. (2015). The child and family migration surge of summer 2014: A short-lived crisis with a lasting impact. Journal of International Affairs, 68, 95–114.
De Hoyos, R., Rogers, H., & Székely, M. (2016). Out of school and out of work: Risk and opportunities for Latin America’s Ninis. Retrieved from https://openknowledge.worldbank.org/handle/10986/22349
Department of Homeland Security. (2016). Statement by Secretary Johnson on southwest border security. Retrieved from https://www.dhs.gov/news/2016/10/17/statement-secretary-johnson-southwest-border-security
Farah, D. (2016). Central America’s gangs are all grown up. Foreign Policy. Retrieved from http://foreignpolicy.com/2016/01/19/central-americas-gangs-are-all-grown-up
Fox, P. G., Burns, K. R., Popovich, J. M., Belknap, R. A., & Frank-Stromborg, M. (2004). Southeast Asian refugee children: Self-esteem as a predictor of depression and scholastic achievements in the U.S. The International Journal of Psychiatric Nursing Research, 9, 1063–1072.
Gonzalez-Barrera, A., Krogstad, J. M., & Lopez, M. H. (2014, July 1). DHS: Violence, poverty, is driving children to flee Central America to U.S. Pew Research Center. Retrieved from http://www.pewresearch.org/fact-tank/2014/07/01/dhs-violence-poverty-is-driving-children-to-flee-central-america-to-u-s
Hernandez-Wolfe, P., Killian, K., Engstrom, D., & Gangsei, D. (2015). Vicarious resilience, vicarious trauma,
and awareness of equity in trauma work. Journal of Humanistic Psychology, 55, 153–172. doi:10.1177/0022167814534322
International Organization for Migration. (2016). Hunger without borders: The hidden links between food insecurity,
violence and migration in the Northern Triangle of Central America. Retrieved from https://environmental
migration.iom.int/hunger-without-borders-hidden-links-between-food-insecurity-violence-and-migration-northern-triangle
Jani, J., Underwood, D., & Ranweiler, J. (2016). Hope as a crucial factor in integration among unaccompanied immigrant youth in the USA: A pilot project. Journal of International Migration and Integration, 17, 1195–1209. doi:10.1007/s12134-015-0457-6
Karaman, M. A., & Ricard, R. J. (2016). Meeting the mental health needs of Syrian refugees in Turkey. The Professional Counselor, 6, 318–327. doi:10.15241/mk.6.4.318
Keller, A., Joscelyne, A., Granski, M., & Rosenfeld, B. (2017). Pre-migration trauma exposure and mental health functioning among Central American migrants arriving at the US border. PLOS One, 12, 1–11.
doi:10.1371/journal.pone.0168692
Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J., . . . Pottie, K. (2011). Common mental health problems in immigrants and refugees: General approach in primary care. Canadian Mental Health Association Journal, 183, 959–967. doi:10.1503/cmaj.090292
Knake, L. (2014, July 14). Protesters carry AR rifles, flags in march against Central American teens coming to Vassar. Mlive. Retrieved from http://www.mlive.com/news/saginaw/index.ssf/2014/07/demonstrators_in_
vassar_carry.html
Krogstad, J. M., Gonzalez-Barrera, A., & Lopez, M. H. (2014). Children 12 and under are fastest growing group of unaccompanied minors at U.S. border. Retrieved from http://www.pewresearch.org/fact-tank/2014/07/22/
children-12-and-under-are-fastest-growing-group-of-unaccompanied-minors-at-u-s-border/#comments
Lonn, M. R., & Haiyasoso, M. (2016). Helping counselors “stay in their chair”: Addressing vicarious trauma in supervision. VISTAS 2016. Retrieved from https://www.counseling.org/knowledge-center/vistas/by-subject2/vistas-crisis/docs/default-source/vistas/article_90_2016
Montgomery, E., & Foldspang, A. (2008). Discrimination, mental problems and social adaptation in young refugees. European Journal of Public Health, 18, 156–161. doi:10.1093/eurpub/ckm073
O’Connor, E. (2012, October 15). Mexico’s Ciudad Juárez is no longer the most violent city in the world. Time. Retrieved from http://newsfeed.time.com/2012/10/15/mexicos-ciudad-juarez-is-no-longer-the-most-violent-city-in-the-world
Office of Refugee Resettlement. (2016). Facts and data. Retrieved from https://www.acf.hhs.gov/orr/about/
ucs/facts-and-data
Overseas Security Advisory Council. (2016). Guatemala 2016 crime & safety report. Retrieved from https://www.osac.gov/Pages/ContentReportDetails.aspx?cid=19279
Padgett, T. (2014, March 19). El Salvador’s new president faces gangs, poverty and instability. NPR: Parallels. Retrieved from https://www.npr.org/sections/parallels/2014/03/19/291428131/el-salvadors-new-president-faces-gangs-poverty-and-instability
Pumariega, A. J., Rothe, E., & Pumariega, J. B. (2005). Mental health of immigrants and refugees. Community Mental Health Journal, 41, 581–597. doi:10.1007/s10597-005-6363-1
Renwick, D. (2016, January 19). Central America’s violent Northern Triangle. Council on Foreign Relations. Retrieved from https://www.cfr.org/backgrounder/central-americas-violent-northern-triangle
Ribando, C. M. (2007). Gangs in Central America (CRS RL34112). Retrieved from the U.S. Department of Justice website: https://www.justice.gov/sites/default/files/eoir/legacy/2013/11/08/crs%20gangs_07.pdf
Sabin, M., Lopes Cardozo, B., Nackerud, L., Kaiser, R., & Varese, L. (2003). Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict. Journal of the American Medical Association, 290, 635–642. doi:10.1001/jama.290.5.635
Sartor, T. A. (2016). Vicarious trauma and its influence on self-efficacy. VISTAS Online 2016. Retrieved from https://www.counseling.org/docs/default-source/vistas/article_2721c024f16116603abcacff0000bee5e7.
pdf?sfvrsn=6
Sawyer, C. B., & Márquez, J. (2017). Senseless violence against Central American unaccompanied minors: Historical background and call for help. The Journal of Psychology, 151, 69–75.
Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three- through six year-old children: A randomized clinical trial. The Journal of Child Psychology and Psychiatry, 52, 853–860. doi:10.1111/j.1469-7610.2010.02354.x
Seelke, C. R. (2016). Gangs in Central America (CRS RL34112). Retrieved from https://fas.org/sgp/crs/row/RL
34112.pdf
Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J., Kolko, D. J., Putnam, F. W., & Amaya-Jackson, L. (2008). Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. Journal of Clinical Child and Adolescent Psychology, 37, 156–183. doi:10.1080/15374410701818293
Stinchcomb, D., & Hershberg, E. (2014). Unaccompanied migrant children from Central America: Context, causes, and responses (CLALS Working Paper Series No. 7). Retrieved from http://ssrn.com/abstract=2524001
Stuber, J., Galea, S., Ahern, J., Blaney, S., & Fuller, C. (2003). The association between multiple domains of discrimination and self-assessed health: A multilevel analysis of Latinos and Blacks in four low-income New York City neighborhoods. Health Services Research, 38, 1735–1759.
doi:10.1111/j.1475-6773.2003.00200.x
Substance Abuse and Mental Health Services Administration. (2014). Trauma-informed care in behavioral health services (HHS Publication No. SMA 13-4801). Rockville, MD: Author.
Tousignant, M. (1992). Migration and mental health—some prevention guidelines. International Migration, 30, 167–177. doi:10.1111/j.1468-2435.1992.tb00782.x
Tribe, R. (2002). Mental health of refugees and asylum-seekers. Advances in Psychiatric Treatment, 8, 240–247. doi:10.1192/apt.8.4.240
Uehling, G. L. (2008). The international smuggling of children: Coyotes, snakeheads, and the politics of compassion. Anthropological Quarterly, 81, 833–871. doi:10.1353/anq.0.0031
United Nations Children’s Fund. (2016). Broken dreams: Central American children’s dangerous journey to the United States. Retrieved from https://www.unicef.org/infobycountry/files/UNICEF_Child_Alert_
Central_America_2016_report_final(1).pdf
United Nations High Commissioner for Refugees. (2015). Global trends: Forced displacement in 2015. Retrieved from http://www.unhcr.org/576408cd7.pdf
United Nations Office on Drugs and Crime. (2011). Global study on homicide. Retrieved from http://www.unodc.
org/documents/data-and-analysis/statistics/Homicide/Globa_study_on_homicide_2011_web.pdf
Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing and Health Sciences, 15, 398–405.
doi:10.1111/nhs.12048
Vervliet, M., Meyer Demott, M. A., Jakobsen, M., Broekaert, E., Heir, T., & Derluyn, I. (2014). The mental health of unaccompanied refugee minors on arrival in the host country. Scandinavian Journal of Psychology, 55, 33–37. doi:10.1111/sjop.12094
Ward, C., Okura, Y., Kennedy, A., & Kojima, T. (1998). The U-curve on trial: A longitudinal study of psychological and sociocultural adjustment during cross-cultural transition. International Journal of Intercultural Relations, 22, 277–291. doi:10.1016/S0147-1767(98)00008-X
Watts, J. (2015, August 22). One murder every hour: How El Salvador became the homicide capital of the world. The Guardian. Retrieved from https://www.theguardian.com/world/2015/aug/22/el-salvador-worlds-most-homicidal-place
Williams, A., Helm, H. M., & Clemens, E. V. (2012). The effect of childhood trauma, personal wellness, supervisory working alliance, and organizational factors on vicarious traumatization. Journal of Mental Health Counseling, 34, 133–153. doi:10.17744/mehc.34.2.j3l62k872325h583
Women’s Refugee Commission. (2012). Forced from home: The lost boys and girls of Central America. New York, NY: Author.
Yardley, L. (2008). Demonstrating validity in qualitative psychology. In J. A. Smith (Ed.), Qualitative psychology:
A practical guide to research methods (2nd ed., pp. 235–251). Thousand Oaks, CA: Sage.
Angelica M. Tello, NCC, is an assistant professor at the University of Houston-Clear Lake. Nancy E. Castellon is a doctoral student at the University of Texas at San Antonio. Alejandra Aguilar is a doctoral student at the University of Houston-Clear Lake. Cheryl B. Sawyer is a professor at the University of Houston-Clear Lake. Correspondence can be addressed to Angelica Tello, 2700 Bay Area Blvd, Houston, Texas, 77058-1002, tello@uhcl.edu.
Nov 25, 2017 | Volume 7 - Issue 4
Stephen P. Hebard, Katie A. Lamberson
Athletes represent a unique population with a legitimate need for counseling services; yet, counselors have done little to define and promote sport counseling. This paper represents a call to counselors, educators, and researchers to advocate for a rigorous sport counseling specialization and clarified professional identity. Counselors need to identify required competencies, teaching guidelines, and ethical codes to provide optimal mental health services to athletes and effectively co-exist among other professionals in sport. The current state of mental health services for athletes, the potential for counselors to provide unique contributions to mental health in sport, and actionable steps regarding advocacy and research are discussed.
Keywords: sport counseling, professional identity, advocacy, athletes, mental health
Athletes represent a considerable segment of the American population. As of 2016, 40% of youth aged 6 to 12 participated in team sports, a 3% increase from 2015 (Rosenwald, 2016). Recent surveys show that 8 million high school students play sports (National Federation of State High School Associations, 2015), about 525,000 participate at the collegiate level (National Collegiate Athletic Association [NCAA], 2017a), and more than 11,800 are considered elite, professional athletes (Bureau of Labor Statistics, 2014). Over the past several years, researchers have recognized that athlete mental health concerns often go largely unaddressed (Ferrante & Etzel, 2009; Nattiv, Puffer, & Green, 1997).
Athletes at every level are often perceived to be privileged and idolized for their physical prowess; however, this perception leaves them especially vulnerable to be missed when it comes to mental health concerns. In fact, as a population, athletes are described as “at-risk” of experiencing a multitude of mental health concerns. Researchers have demonstrated that athletes are susceptible to alcohol abuse (B. E. Miller, Miller, Verhegge, Linville, & Pumariega, 2002), lower levels of wellness than non-athletes (Watson & Kissinger, 2007), risky behaviors (Nattiv et al., 1997), depression (Nixdorf, Frank, Hautzinger, & Beckmann, 2013; Storch, Storch, Killiany, & Roberti, 2005; Yang et al., 2007), social anxiety (Storch et al., 2005), eating disorders (Currie & Morse, 2005), and aggression (Benedict & Yaeger, 1998), among other mental health issues. Many of these mental health concerns may result from the demands and pressures experienced by athletes. For example, some athletes have been found to over-train, which may result in depression, decreased self-esteem, or emotional instability (Raglin & Wilson, 2000). Furthermore, athletes are less likely to seek professional help than their non-athlete counterparts for mental health concerns (López & Levy, 2013; Watson, 2005). Given the growth of sport from youth to adulthood and the challenges to mental health inherent in sport participation, mental health professionals can provide support to athletes that is currently lacking. However, in order to deliver optimal care, mental health professionals must commit themselves to fully understanding the athlete experience.
Counselors are in a position to provide unique, culturally responsive mental health services to athletes; however, the profession’s presence in sport is limited due to a poorly defined professional identity and a lack of understanding of the unique skill set counselors possess. A lack of empirically derived competencies, teaching guidelines, and ethical considerations must be addressed if sport counselors hope to have a greater presence in sport. Additionally, competition with sport psychologists, who primarily address athletic performance optimization and are currently far more integrated into athlete culture, may be a barrier for counselors. However, because sport psychologists primarily educate athletes on mental skills for performance optimization and counselors directly address mental health concerns, there is room for these professionals to work together to address the overall wellness and performance needs of athletes.
The purpose of this paper is to discuss the current state of mental health services provided to athletes and to identify and address the potential barriers for counselors who wish to work in sport. In addition, the authors will provide a brief history of a vision for an integrated sport counseling specialty, gaps in counselor competence and identity necessary to establish sport counseling among widely recognized professions in sport, and suggestions for researchers, practitioners, and advocates to ensure a future for the sport counseling specialty.
The Evolution of Mental Health Services in Sport
The unique challenges of athletes were first identified in the early 1970s by a group of college counselors that would later form the National Association for Academic Advisors of Athletics (N4A; National Association of Academic and Student-Athlete Development Professionals, 2017). Their commitment to encouraging student athlete academic achievement led to an expansion of their initiative beyond academics and a moniker representative of their current mission (the National Association of Academic and Student-Athlete Development Professionals). N4A’s impact is experienced by over 40,000 athletes annually, as the organization was integral in the development of the NCAA’s CHAMPS/Life Skills (now NCAA Life Skills) program. N4A and the NCAA Life Skills program define their commitment as one that impacts athlete academic achievement, athletic performance, and personal well-being. Although there is little doubt that these programs positively impact athletes, their focus is not specific to mental health. In fact, until the early 2010s, sport organizations had done little advocacy for athletes experiencing mental health challenges. In 2013, the National Athletic Training Association (NATA) made a call for mental health practitioners to help increase mental health awareness within athletics organizations (Neal et al., 2013). NATA published recommendations for athletic trainers, who are considered the “first responders” to both physical and mental health (Burnsed, 2013a), to develop a collaborative plan to recognize and refer student athletes experiencing psychological concerns to the appropriate mental health professionals. In doing so, NATA catalyzed a long overdue shift in the philosophy and attention of stakeholders invested in the overall well-being of athletes. Soon thereafter, the NCAA (2014) recruited a Mental Health Task Force to demonstrate substantial commitment to the prioritization of mental health concerns experienced by student athletes. This task force is committed to working with coaches, medical providers, and student athletes to address the stigma commonly associated with mental health issues and how to break through barriers to mental health access (Burnsed, 2013b). Despite the positive goals the NCAA aims to achieve, counselors have yet to be represented on this task force.
Similar to these shifts at the collegiate level, professional organizations have made some strides toward recognizing the mental health needs of their athletes. For example, the National Football League (NFL)-affiliated Player Engagement Division currently provides active players with the “NFL Life Line.” The NFL Life Line is a crisis hotline for current and former NFL players that offers independent, confidential support (NFL Life Line, 2016). The actions of NATA, the NCAA, and the NFL represent a significant investment in athlete mental health that had previously been missing from the history of health considerations in sport. Recent emphasis on addressing athlete mental health issues marks a necessary and exciting opportunity for the counseling profession; yet, sport psychologists currently dominate this work, despite noted differences in focus. In order to become part of the solution to addressing the mental health needs of athletes at all levels, counselors must prioritize advocacy for athlete mental health and be able to competently describe how their involvement in sport will benefit athletes across the lifespan. A first step for counselors is to better understand the current mental health services that exist for athletes.
The majority of individualized attention to psychologically related services offered to athletes (both collegiate and professional) has historically been provided by practitioners of sport psychology. Two primary organizations exist within the sport psychology profession: the Association for Applied Sport Psychology (AASP) and American Psychological Association (APA) Division 47. AASP certifies master’s-level “consultants” who display competence in kinesiology and psychology to educate athletes on the role of psychological factors in sport performance and teach mental skills that athletes can utilize within and beyond the context of their sport (AASP, 2017). In contrast, APA refers to sport psychology as a specialization within the general practice of psychology for doctoral-level psychologists (APA, 2017). Clinical sport psychologists with proficiency through Division 47 provide clinical interventions for eating disorders, substance use, grief, depression, sexual identity issues, aggression, career transitions, and more (APA, 2017). Practical, organizational, and philosophical differences between these two primary organizations have challenged the sport counseling specialty to establish a unique identity (Aoyagi, Portenga, Poczwardowski, Cohen, & Statler, 2012). Both AASP and Division 47 identify performance optimization as a primary responsibility of sport psychologists, though licensed psychologists with the Division 47 sport psychology proficiency claim specialized knowledge in clinical and counseling issues with athletes and biobehavioral bases of sport and exercise. As a result, athletes seeking mental health services are likely to receive services from sport psychologists with disparate levels of education, varying degrees of competence, and significant differences in their goals for treatment.
This lack of potential continuity of services, coupled with the unique contributions of counseling in sport, marks an opportunity for counselors to become a major resource among athletes. Counselors can address the current discrepancy in services by approaching athlete mental health concerns from a bottom-up, rather than top-down, approach. Counselors can utilize their strength-based, wellness-oriented philosophy to prioritize mental health needs over performance in efforts to enhance performance through improving overall wellness, rather than the reverse. Specialty training in sport can create a more streamlined set of competencies and standards that fall within the general counseling guidelines, but still cater to the unique needs of athletes. Acknowledging the limitations of sport counseling’s history and its current status may encourage clarification of an identity, development of competencies and standards, and recognition of the important contributions that counseling can bring to the culture of athletics.
Sport Counseling: Past and Present
The idea of a sport counseling specialty is hardly new. In 1985, the Counselors of Tomorrow Interest Network of the Association for Counselor Education and Supervision (ACES) described a number of potential counseling specializations for exploration in their publication, Imagine: A Visionary Model for the Counselors of Tomorrow (Nejedlo, Arredondo, & Benjamin, 1985). This publication included a brief section that defined “athletic counseling” and listed associated skills (e.g., counseling, goal setting) and knowledge bases (e.g., NCAA regulations, group facilitation) necessary for practice (Nejedlo et al., 1985). Researchers and educators have since heralded the document as the foundation for defining sport counseling and the treatment of athletes. However, the purpose of this publication was not to establish fundamental principles and standards, but to outline trends, future work environments, and specialty roles in a number of different areas of counseling (Arredondo & Lewis, 2001). The authors did not intend for this list of knowledge bases and skills to serve as a rigorously developed set of competencies for counseling athletes. The intent was to provide a primer for future considerations in sport counseling. The Imagine publication does promote an apparent commitment to a wellness orientation with athletes; however, it serves as the first brick in a foundation for counselors to stand upon, not a jumping-off point for pedagogy and practice.
Hinkle (1989a, 1989b) continued to push for an established sport counseling specialty in papers presented at the Southeastern Psychological Association and Southern ACES. Hinkle also established the ACES Sports Counseling Interest Network in 1992, and the first meeting of the group was held at the American Counseling Association conference in Baltimore (J. S. Hinkle, personal communication, November 13, 2017). In two separate publications, Hinkle (1994) and Petitpas, Buntrock, Van Raalte, and Brewer (1995) made similar arguments that sport counselors must focus on the developmental and emotional aspects of the individual rather than performance optimization and mental skills training. Hinkle (1994) continued by discussing integrated treatment for athletes that included sport psychology, counseling, and developmental and educational programming, highlighting the unique contribution of each profession and the importance of taking a team approach to fully address the diverse needs of athletes. In addition, Hinkle discussed how sport counselors may work with clinical issues, career and life planning, programs for children, and a research agenda.
Though little formal evidence exists, several hurdles have impacted forward progress in the sport counseling arena. For example, there is anecdotal evidence that counselors may view athletes as a population unworthy of services. When asked why G. M. Miller and Wooten’s (1995) sport counseling proposal to the Council for Accreditation of Counseling and Related Educational Programs (CACREP) was never adopted, H. R. Wooten shared, “It appeared that working with athletes was a little ‘boutique’ for most counselors as athletes continued to be seen as privileged” (personal communication, May 27, 2014). Poor visibility among other health professionals working in sport, few opportunities for supervised internships due to a lack of licensed professionals working in sport, limited counseling research with athlete populations, and minimal commitment to athlete mental health until recent years all may have had an effect on the pace at which sport counseling has advanced. Despite counseling researchers’ and advocates’ efforts to move sport counseling forward, more than 20 years later, counselors remain committed to the descriptors of the Imagine publication, but need clarity in professional identity and service provision.
At present, counselors who desire specialized knowledge in working with athletes may be confused by the way that the specialty is being defined and marketed. For example, athletic counseling, is a term used to market academic programs that prepare students for AASP certification and employment in applied sport psychology. Graduates of these programs are not counselors; rather, they meet criteria necessary to be recognized as a Certified Consultant of the Association for Applied Sport Psychology (CC-AASP). A CC-AASP is recognized as an individual trained to enhance athletic performance through mental skills training (AASP, 2017), but it is not a credential that prepares individuals to provide counseling to athletes. A CC-AASP does not participate in many of the typical responsibilities of counselors, including the diagnosis of mental health disorders, substance abuse counseling, and marital or family counseling (AASP, 2017). Counseling certificate programs also utilize the athletic counseling moniker to market their specialized curriculum to licensed counselors, suggesting these programs see a benefit in providing additional training in athletics to individuals already trained as counselors. This model recognizes that the foundational knowledge and skills essential to licensed counselors are important regardless of population or setting. Thus, specialized training related to working in athletics in addition to the core training of licensed counselors may be the best way to maintain cohesion within the counseling profession while still providing athletes with the specialized services they need. Unfortunately, confusion among athletes, coaches, administrators, and other professionals exists because there is a lack of significant knowledge of sport and mental health, which may be the result of a lack of a clear model within the mental health professions about what sport counseling should look like and the distinctive role sports counselors can have when working with athletes. We believe that a commitment to establishing a clearer sport counseling identity would distinguish sport counseling programs like those at Springfield College, California University of Pennsylvania, and Adler University from other programs and would provide enhanced opportunities for graduates wanting to work in athletics.
Implications and Future Directions for Sport Counseling Researchers and Practitioners
Counselors must consider the question: “If the need for sport counselors exists, why haven’t they proliferated among sport organizations?” This question is not easily answered without significant inquiry; still, there is evidence that begins to tell the story. Certainly, the ubiquity of a stigma against mental health in athletics has historically inspired hesitation to seek help (Brewer, Van Raalte, Petitpas, Bachman, & Weinhold, 1998). In fact, counselors are no strangers to this stigma. Historically, individuals have hesitated to seek assistance for mental health concerns due to the societal stigma mental health carries. Over the years, education and awareness efforts have decreased mental health stigma; however, the profession of counseling has continued to struggle with identifying itself as a profession distinct from other mental health professions (Remley & Herlihy, 2016). To mitigate this struggle, counselors have worked tirelessly to educate and advocate for the professional identity of counselors. In doing so, counselors have utilized Nugent’s (1980) guidelines for identifying a mature profession to gain professional distinction (Remley & Herlihy, 2016). These guidelines include having a clearly defined role and scope of practice, offering unique services, having specialized knowledge and skills, having a code of ethics, obtaining legal rights to offer services through licensure and certification, and having an ability to monitor professional practice (Nugent, 1980). In order to achieve these criteria, some members of the profession promote viewing counseling as the predominant profession with specialty areas that continue to support the primary profession (Remley & Herlihy, 2016). As one of the potential specialties, the area of sport counseling can learn from the progress the primary profession of counseling has accomplished. Utilizing the parallels present in the journey of the counseling profession as an example, sport counseling also can develop a mature identity within the counseling profession. Despite this area’s history and obstacles to proliferation, there are many ways that counselors can play an active role in building the sport counseling specialty.
Counselors interested in working with athletes must focus on the development of a comprehensively developed identity. Sport counseling lacks dedicated documentation of the behaviors that practitioners perform. The values and beliefs that distinguish sport counseling from related professions need to be identified. At minimum, the development of competencies, teaching and practice guidelines, and ethical codes are necessary to establish an identity that is separate but compatible with existing services for athletes, while still remaining true to the overall counseling profession. As advocates of a sport counseling specialization begin to take concrete steps toward promoting professional identity, practitioners may be better able to market themselves to stakeholders and find opportunities to begin meeting the mental health needs of athletes.
The 20/20 Vision for the Future of Counseling (20/20; Kaplan & Gladding, 2011) marks an important step in the establishment of a clear and succinct philosophy representative of all counselors. The 20/20 research team used Delphi methodology, an approach to structuring and organizing experts to come to consensus on an area of incomplete knowledge (Powell, 2003), to invite leaders in counseling to determine an updated, more appropriate definition to clarify the profession’s identity (Kaplan & Gladding, 2011). In an effort to unify as one counseling profession, counselors advocating for a distinct sport counseling specialty must consider 20/20 as an opportunity to enhance its professional identity. The development of a disparate or duplicated area would result in further fragmentation. Ultimately, the authors believe that a sport counseling specialty would be best defined by starting with our already existing 20/20 philosophy: “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan, Tarvydas, & Gladding, 2014, p. 366). Further, 20/20 may serve as an important launching pad from which sport counseling advocates can begin to stake out their domain.
A first step in the establishment of the sport counseling specialty is the rigorous development of competencies that are germane to the practice of working with athletes. Competencies, knowledge, skills, and attributes that represent professional qualifications necessary for effective practice may help sport counselors understand and communicate their identity. A lack of an empirically derived set of sport counseling competencies limits sport counselors’ ability to establish their identity and expertise. Researchers should consider the use of Delphi methodology to determine knowledge, skills, and attributes necessary to treat athlete mental health needs at the highest level. Delphi has been performed effectively to outline guidelines for competence in other areas of counselor education (Wester & Borders, 2014), providing evidence for its potential effectiveness in establishing sport counseling competencies. Future considerations for sport counseling competencies may include understanding the demands of the athletic experience, privacy concerns associated with athletic settings, the role of physiology in sport, the influence of competitive environments on mental health, sport culture, the importance of building relationships with athletes and associated individuals (e.g., coaches, athletic trainers, administrators), and additional athlete-specific issues. Researchers might consider querying counselors in practice with athletes, instructors teaching sport counseling courses in counselor education programs, clinical and applied sport psychologists, athletes, and other relevant parties in sport to establish specific areas of competence necessary for sport counselors.
Leaders in sport counseling must also revisit and revise G. M. Miller and Wooten’s (1995) proposed teaching guidelines published in the Journal of Counseling & Development in 1995. G. M. Miller and Wooten cited Nejedlo et al.’s (1985) aforementioned publication and the Association for the Advancement of Applied Sport Psychology (now AASP) as foundational influences on curriculum development. The curriculum was meant to be integrated with the common core and clinical experiences required by CACREP to provide training standards necessary for practice in sport counseling. The 1995 teaching guidelines were ultimately published, but a plan for their adoption was never established. G. M. Miller and Wooten’s publication serves as an important step toward the integration of sport counseling and counselor education that needs to be addressed more fully. A foundation of researched and well-reasoned competencies will eventually give way to curricular guidelines to anchor and clarify sport counseling identity, practice, and ethics.
The adoption of a new code of ethics may not be necessary; however, there are special circumstances for counselors to consider when working with athletes and sports organizations. For example, ethical standards related to confidentiality and relationships with other professionals can apply to working with athletes, coaches, and other athletic staff; however, more explicit statements related to exceptions to confidentiality and how to work effectively on behalf of the athlete while still respecting a referral from a coach may be helpful for counselors working in athletic settings. Sport counselors may find it prudent to learn from sport psychologists, who typically navigate similar work environments. According to sport psychologists Etzel and Watson (2007), several ethical challenges exist that may present themselves on a daily basis.
One primary ethical challenge that sport counselors may face is determining who their client is when working with individual athletes on a professional or university team. Athletic departments responsible for paying for mental health services, as well as coaches and support staff, may assume that they should be made aware of an athlete’s mental health status. Etzel and Watson (2007) pointed out that athletes are perceived by their managers as controlled investments; there is an expectation of being informed and in control. Ethical guidelines must be made clear for sport counselors to negotiate such challenging situations. Additional challenges include navigating multiple roles (e.g., counselor, team consultant, advisor to coaches), impromptu consultations that occur outside of the counseling session, NCAA and professional rules and regulations, and the likely possibility that other parties will notice an athlete seeking the professional’s services if housed in a university or team setting, among countless other potential dual relationships. The establishment of competencies, training guidelines, and ethical standards that apply specifically to counselor–athlete and counselor–team relationships may appear to be a daunting task. Counselors and counselor educators interested in sport must collaborate and advocate for a strongly anchored position in athletics by committing to the development of these foundational elements of sport counseling practice.
Counselors must acknowledge existing and potential outlets for collaboration if sport counseling is to evolve. The ACES Sports Counseling Interest Network, started by Hinkle in 1992, provides a space for counselors interested in discussing present challenges and supports to the growth of sport counseling. Utilization of this medium for collaboration on future research and presentations is vital to the health and expansion of this specialty. Counselors must consider the importance of offering psychoeducational workshops, connecting athletes to mentorship, and developing other organizational supports for athletes in need. These efforts will help to rightly justify counselors’ push for professional inclusion in sporting contexts. An early step will be to normalize the existence of sport counselors among other professionals advocating for improvements to athlete mental health. Counselor membership on the NCAA Mental Health Task Force is a necessary step to becoming a more widely known and respected entity. As sport counselors become more mainstream and accepted professionals in sport, licensed counselors could provide opportunities to counselors-in-training who require supervised internships before starting their careers as sport counselors. Without active networks for collaboration, counselors remain isolated and perhaps less likely to catalyze change.
Developing these professional relationships is critical to gaining entry and contributing to change in sport. Collaborations with organizations committed to athlete health could encourage other like-minded organizations to consider the expertise of counselors. For example, the Institute to Promote Athlete Health and Wellness (IPAHW) at the University of North Carolina at Greensboro, in collaboration with Prevention Strategies, LLC, is an organization committed to the improvement of athlete health and wellness through behavioral intervention programs, policy making, evidence-based training, and intervention evaluation. IPAHW has collaborated with the NCAA Sport Science Institute to ensure that student athletes have access to “myPlaybook: The Freshman Experience,” a catalog of web-based trainings that facilitate behavior change in student athletes across topics like: social norms related to alcohol and drug use, bystander intervention, mental health, time management, hazing, sleep wellness, and sport nutrition (IPAHW, 2017; J. J. Milroy, personal communication, October 3, 2017). Additionally, IPAHW and the NCAA Sport Science Institute are rolling out a new sexual violence prevention course in response to the NCAA’s new policy that requires coaches, student athletes, and administrators to receive sexual violence prevention education (NCAA, 2017a). Counselors have significant training and expertise that may enhance the work of these organizations advocating for health promotion among athlete populations.
Sport counselors must aim to publish athlete mental health research and seek grant funding for experimental research to further establish this specialty. Though relatively new itself, sport psychology has established several journals that address both performance-oriented (e.g., Journal of Applied Sport Psychology) and clinical (e.g., Journal of Clinical Sport Psychology) issues in sport that have yet to be fully explored by counseling researchers. A solidly established sport counselor identity may lead to the eventuality of a sport counseling journal; however, there is a current lack of leadership committed to this task. As the foundational elements detailed above are established to move sport counseling forward, a journal will become a necessity for researchers to expand their knowledge of athlete mental health needs and counselor interventions. Sport counseling researchers publishing in counseling and related journals may need to consider opportunities to fund experimental pilots and larger scale projects. Opportunities for grant funding in sport, although few, are available and range in size and scope. The National Institutes of Health has committed significant funding to the diagnosis of chronic traumatic encephalopathy, a progressive, degenerative brain disease diagnosed at a high rate among deceased athletes of the NFL (Diagnose CTE, 2017). The Center for Healthy African American Men through Partnerships (2017) has expressed interest in funding research on head trauma in athletes. The NCAA annually supports researchers with pilot funding for alcohol abuse intervention and innovative projects designed to enhance student athlete well-being (NCAA, 2017b). Counseling researchers have not procured funding through these opportunities.
Conclusion
More than ever, Myers, Sweeney, and White’s (2002) assertions that counselors must establish their professional identity, enhance their public image, and develop strong interprofessional, collaborative networks remain both relevant and necessary. Counselors currently attempting to break into the safeguarded culture of athletics may struggle to establish credibility and communicate a unified identity. Currently, counselors in sport have a small foundation to stand upon when discussing the specialization of their services to athletes and athletic staffs. The gaps to be filled are clearly labeled and ready to be addressed. The future of sport counseling requires bolstering the literature that outlines its professional development. Counselors involved in sport need to develop relevant research initiatives, obtain funding, and pilot experimental studies that show evidence of improved mental health outcomes with athletes. The marketability of a sport counselor relies on the ability to demonstrate effectiveness with athletes and collaborate with the professional fields that currently saturate sporting contexts. The prospect of a thriving sport counseling specialty is within the counseling profession’s reach. Counselors must now cultivate a sport counseling identity that clearly projects their viability, marketability, and potential for positively influencing athlete mental health.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
References
American Psychological Association. (2017). Sport psychology. Retrieved from http://www.apa.org/ed/graduate/specialize/sports.aspx
Aoyagi, M. W., Portenga, S. T., Poczwardowski, A., Cohen, A. B., & Statler, T. (2012). Reflections and directions: The profession of sports psychology past, present, and future. Professional Psychology: Research and Practice, 43, 32–38. doi:10.1037/a0025676
Arredondo, P., & Lewis, J. (2001). Counselor roles for the 21st century. In D. C. Locke, J. E. Myers, & E. L. Herr (Eds.), The handbook of counseling (pp. 257–267). Thousand Oaks, CA: Sage.
Association for Applied Sport Psychology. (2017). About certification. Retrieved from http://www.appliedsport
psych.org/certification
Benedict, J., & Yaeger, D. (1998). Pros and cons: The criminals who play in the NFL. New York, NY: Warner Books.
Brewer, B. W., Van Raalte, J. L., Petitpas, A. J., Bachman, A. D., & Weinhold, R. A. (1998). Newspaper portrayals of sport psychology in the United States, 1985–1993. The Sport Psychologist, 12, 89–94.
Bureau of Labor Statistics (2017). Athletes and sports competitors. Retrieved from https://www.bls.gov/ooh/entertainment-and-sports/athletes-and-sports-competitors.htm
Burnsed, B. (2013a). First responders: Athletic trainers are a team’s first line of defense. Retrieved from http://www.ncaa.org/champion/first-responders
Burnsed, B. (2013b). NCAA Mental Health Task Force holds first meeting. Retrieved from http://www.ncaa.org/about/resources/media-center/news/ncaa-mental-health-task-force-holds-first-meeting
Center for Healthy African American Men through Partnerships. (2017). Scholars disparities program. Retrieved from https://chaamps.com/blog/new-research-funding-opportunity
Currie, A., & Morse, E. D. (2005). Eating disorders in athletes: Managing the risks. Clinical Sports Medicine, 24, 871–883. doi:10.1016/j.csm.2005.05.005
Diagnose CTE. (2017). Goals of the DIAGNOSE CTE research project. Retrieved from http://diagnosecte.com/projectgoals
Etzel, E. F., & Watson, J. C., II. (2007). Ethical challenges for psychological consultations in intercollegiate athletics. Journal of Clinical Sport Psychology, 1, 304–317. doi:10.1123/jcsp.1.3.304
Ferrante, A. P., & Etzel, E. F. (2009). College student-athletes and counseling services in the new millennium. In E. F. Etzel (Ed.), Counseling and psychological services for college student-athletes (pp. 1–50). Morgantown, WV: Fitness Information Technology.
Hinkle, J. S. (1989a, March). Sports counseling: The process and the product. In J. S. Hinkle (Chair), Sport psychology: Perspectives on sports counseling. Symposium conducted at the 35th Annual Meeting of the Southeastern Psychological Association, Washington, DC.
Hinkle, J. S. (1989b, October). Sports counseling. Paper presented at the Annual Southern Association for Counselor Education and Supervision Conference, Orlando, FL.
Hinkle, J. S. (1994). Integrating sport psychology and sports counseling: Developmental programming, education, and research. Journal of Sport Behavior, 17, 52–59.
Institute to Promote Athlete Health and Wellness. (2017). myPlaybook. Retrieved from https://athletewellness.uncg.edu/myplaybook
Kaplan, D. M., & Gladding, S. T. (2011). A vision for the future of counseling: The 20/20 principles for unifying and strengthening the profession. Journal of Counseling & Development, 89, 367–372.
doi:10.1002/j.1556- 6678.2011.tb00101.x
Kaplan, D. M., Tarvydas, V. M., & Gladding, S. T. (2014). 20/20: A vision for the future of counseling: The new consensus definition of counseling. Journal of Counseling & Development, 92, 366–372.
doi:10.1002/j.1556-6676.2014.00164.x
López, R. L., & Levy, J. J. (2013). Student athletes’ perceived barriers to and preferences for seeking counseling. Journal of College Counseling, 16, 19–31. doi:10.1002/j.2161-1882.2013.00024.x
Miller, B. E., Miller, M. N., Verhegge, R., Linville, H. H., & Pumariega, A. J. (2002). Alcohol misuse among college athletes: Self-medication for psychiatric symptoms? Journal of Drug Education, 32, 41–52. doi:10.2190/JDFM-AVAK-G9FV-0MYY
Miller, G. M., & Wooten, H. R., Jr. (1995). Sports counseling: A new counseling specialty area. Journal of Counseling & Development, 74, 172–173. doi:10.1002/j.1556-6676.1995.tb01845.x
Myers, J. E., Sweeney, T. J., & White, V. E. (2002). Advocacy for counseling and counselors: A professional imperative. Journal of Counseling & Development, 80, 394–402. doi:10.1002/j.1556-6678.2002.tb00205.x
National Association of Academic and Student-Athlete Development Professionals. (2017). History and evolution of N4A – The National Association of Academic and Student-Athlete Development Professionals. Retrieved from http://grfx.cstv.com/photos/schools/nacda/sports/nfoura/auto_pdf/2017-18/misc_non_event/n4ahistory071117.pdf
National Collegiate Athletic Association. (2014). Mind, body, and sport: Understanding and supporting student-athlete mental wellness. Indianapolis, IN: Author.
National Collegiate Athletic Association. (2017a). Board adopts sexual violence policy. Retrieved from http://www.ncaa.org/about/resources/media-center/news/board-adopts-sexual-violence-policy
National Collegiate Athletic Association. (2017b). NCAA CHOICES grant. Retrieved from http://www.ncaa.org/sport-science-institute/ncaa-choices-grant
National Federation of State High School Associations. (2015). 2014-15 high school athletics participation survey. Retrieved from http://www.nfhs.org/ParticipationStatics/PDF/2014-15_Participation_Survey_Results.pdf
National Football League Life Line. (2016). Get support now. Retrieved from https://nfllifeline.org/get-support-now
Nattiv, A., Puffer, J. C., & Green, G. A. (1997). Lifestyles and health risks of collegiate athletes: A multi-center study. Clinical Journal of Sport Medicine, 7, 262–272.
Neal, T. L., Diamond, A. B., Goldman, S., Klossner, D., Morse, E. D., Pajak, D. E., . . . Welzant, V. (2013).
Inter-association recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the collegiate level: An executive summary of a consensus statement. Journal of Athletic Training, 48, 716–720. doi:10.4085/1062-6050-48.4.13
Nejedlo, R. J., Arredondo, P., & Benjamin, L. (1985). Imagine: A visionary model for counselors of tomorrow. DeKalb, IL: George’s Printing.
Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7, 313–326.
doi:10.1123/jcsp.7.4.313
Nugent, F. (1980). Professional counseling: An overview. Pacific Grove, CA: Brooks/Cole.
Petitpas, A. J., Buntrock, C. L., Van Raalte, J. L., & Brewer, B. W. (1995). Counseling athletes: A new specialty in counselor education. Counselor Education and Supervision, 34, 212–219.
doi:10.1002/j.1556-6978.1995.tb00243.x
Powell, C. (2003). The Delphi technique: Myths and realities. Journal of Advanced Nursing, 41, 376–382. doi:10.1046/j.1365-2648.2003.02537.x
Raglin, J. S., & Wilson, G. S. (2000). Overtraining in athletes. In Y. Hanin (Ed.), Emotions in sport (pp. 191–207). Champaign, IL: Human Kinetics.
Remley, T. P., Jr., & Herlihy, B. (2016). Ethical, legal, and professional issues in counseling (5th ed.). Upper Saddle River, NJ: Pearson.
Rosenwald, M. S. (2016, May 17). Youth sports participation is up slightly, but many kids are still left behind. The Washington Post. Retrieved from https://www.washingtonpost.com/news/local/wp/2016/05/17/youth-sports-participation-is-up-slightly-but-many-kids-are-still-left-behind/?utm_term=.d9bca4eae1cb
Storch, E. A., Storch, J. B., Killiany, E. M., & Roberti, J. W. (2005). Self-reported psychopathology in athletes: A comparison of intercollegiate student-athletes and non-athletes. Journal of Sport Behavior, 28, 86–98.
Watson, J. C. (2005). College student-athletes’ attitudes toward help-seeking behavior and expectations of counseling services. Journal of College Student Development, 46, 442–449. doi:10.1353/csd.2005.0044
Watson, J. C., & Kissinger, D. B. (2007). Athletic participation and wellness: Implications for counseling college student-athletes. Journal of College Counseling, 10, 153–162. doi:10.1002/j.2161-1882.2007.tb00015.x
Wester, K. L., & Borders, L. D. (2014). Research competencies in counseling: A Delphi study. Journal of Counseling & Development, 92, 447–458. doi:10.1002/j.1556-6676.2014.00171.x
Yang, J., Peek-Asa, C., Corlette, J. D., Cheng, G., Foster, D. T., & Albright, J. (2007). Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clinical Journal of Sports Medicine, 17, 481–487. doi:10.1097/JSM.0b013e31815aed6b
Stephen P. Hebard, NCC, is an assistant professor at the University of Alabama at Birmingham. Katie A. Lamberson is an assistant professor at the University of North Georgia. Correspondence concerning this article should be addressed to Stephen Hebard, Department of Human Studies, The University of Alabama at Birmingham, 1720 2nd Ave S., EB 207, Birmingham, AL 35294-1250, sphebard@uab.edu.
