Szu-Yu Chen, Dareen Basma, Jennie Ju, Kok-Mun Ng
Distance counselor education has expanded educational opportunities for diverse groups of students. To effectively train and support global students in counseling programs, the authors explore some unique challenges and opportunities that counselor educators may encounter when integrating technology in the multicultural counseling curriculum. The authors discuss pedagogical strategies that can enhance distance learners’ multicultural and social justice counseling competencies. Through an intersectional, social construction pedagogy, counselor educators can decolonize traditional multicultural counseling curricula and foster an international distance learning environment. Additional innovative approaches and resources, such as online multiculturally oriented student services, online student-centered multiculturally based organizations and workshops, and office hours for mentoring online international students and supporting distance learners’ needs, are described.
Keywords: distance counselor education, multicultural, international, online education, social justice
The growth in distance learning has led to an integration of technology in the curriculum over the past two decades (Allen et al., 2016). Counselor educators now can deliver distance learning courses internationally via videoconference systems, such as two-way audio and video software programs, for students to attend classes either synchronously or asynchronously (Snow et al., 2018), and many programs are moving toward distance education (Benshoff & Gibbons, 2011; Reicherzer et al., 2009). This shift in educational platforms allows both domestic and international students to receive counselor education and training remotely without having to commute or leave their home countries. For example, the counselor education program at the institution of the first three authors currently has over 300 students from the five most populous continents in various stages of counselor preparation. Distance education has expanded educational opportunities, targeted underserved groups of students, and given space for the formation of a more globally diverse student body (Columbaro, 2009; Gillies, 2008).
With the dramatic increase of diversity and attention to racism and other forms of human oppression in the United States, by the early 2000s, the issues of multiculturalism and social justice had come to the center of the counseling profession (Arredondo, 1999) and were recognized as two sides of the same coin (Ratts, 2011). As a result, multicultural education in the profession has been aimed at enhancing students’ awareness of cultural diversity and social justice in counseling relationships and implementation of advocacy competencies as they grapple with power, privilege, and oppression at the individual and systemic levels (Ratts et al., 2015). More recently, the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2015) has integrated a social justice and advocacy component into the framework of multicultural counseling competencies developed in 1992 by Sue, Arredondo, and McDavis, and highlighted the intersection of identities and the role power, privilege, and oppression play in the counseling relationship. The American Counseling Association (ACA; 2014) has also asserted that “counselor educators actively infuse multicultural/diversity competency in their training and supervision practices. They actively train students to gain awareness, knowledge, and skills in the competencies of multicultural practice” (F.11.c). Yet there seems to be a lack of attention in the literature to how online training programs can address global students’ multicultural and social justice counseling competencies given their non-traditional modes of learning delivery. With the emphasis on the helping relationship in the counseling profession, instructors who teach online face additional challenges because of a lack of in-person contact with students and may feel skeptical about the effectiveness of creating a safe and interactive space virtually, especially in relation to addressing challenging and complex topics (Hall et al., 2010).
It is worth noting that many counselor educators have not received formal pedagogical education and training on integrating technology into their curriculum and developing effective online courses (Cicco, 2012). This impacts educators’ feelings of discomfort or lack of preparedness when developing and delivering an online international multicultural counseling course, as well as facilitating discussions about multicultural issues and developing global students’ multicultural and social justice counseling training and competencies through an online medium. Consequently, when considering the development of an online multicultural counseling course, educators have to not only grapple with the complexity of designing a nuanced curriculum, but also negotiate delivery of a curriculum on an evolving learning platform in which international students who do not reside in the United States are integrated into the learning experience. As such, there are several opportunities and challenges to consider when facilitating multicultural and social justice counseling training on an online platform.
To effectively retain and support global students with diverse backgrounds and learning styles in distance counseling programs, herein we explore challenges and opportunities that counselor educators encounter when integrating technology in the multicultural and social justice counseling curriculum. Specifically, we want to discuss pedagogical strategies that we have found valuable to enhancing global learners’ multicultural and social justice counseling competencies. With the movement toward internationalizing the counseling profession, we believe that counselor educators can decolonize the traditional multicultural counseling curriculum and promote global students’ multicultural and social justice advocacy competencies through an intersectional and social construction online pedagogy and further cultivate an inclusive global learning environment. Additionally, we want to share innovative approaches counselor educators can use to support global students’ needs and enhance student retention in online counseling programs.
Internationalization of Multicultural Counseling Education in the Virtual Classroom
In international distance education, each student may differ in experiences of culture, cultural identities, and developmental level of multicultural counseling and social justice competencies. To address the increase in a globally diverse student body, the counseling profession is transforming from a Western-based to a global-based practice (Lorelle et al., 2012). Historically, textbooks and journal articles in the United States regarding diversity are typically monoculture in nature, focusing primarily on social identities such as race, ethnicity, gender, and social class that are commonly found in U.S.-based diversity discourse (Case, 2017). Students who live abroad may find these materials and foci disconnected from their contexts and not applicable to their practice. Consequently, these students can become less engaged in the learning experience.
The movement toward internationalizing the counseling profession over the past two decades has highlighted the need to extend multicultural competencies in ways that are relevant to mental health services beyond U.S. borders. Relatedly, Harley and Stansbury (2011) asserted that the multicultural movement needs to take place at two levels. On the first level, it requires our diligence to recognize, learn about, and appreciate the cultural diversity that exists on U.S. soil. The second level requires us to develop a global perspective that recognizes other cultures and sociopolitical forces that impact the lived experiences of people in other countries. Other scholars (e.g., Bhat & McMahon, 2016; Knight, 2004; Ng et al., 2012) also acknowledge these two dimensions in efforts to internationalize the counseling profession and emphasize the need to address the underdevelopment of cross-national multicultural competencies.
To date, systematic discourse related to international students’ learning experiences and perspectives in online training programs remains limited. To respond to this shift in distance counselor education, we propose adding a third dimension—the internationalization of counselor education—to the two levels of multicultural education proposed by Harley and Stansbury (2011). This third multicultural dimension requires a conceptualization of cultures and ways of being into a counseling curriculum that maintains a global and international perspective. Thus, learning is comprised of training activities and programs designed to prepare students to provide culturally responsive counseling services and advocacy that are simultaneously informed by both a local and global perspective.
Counselor educators are aware of the enormity of some of the challenges associated with the movement toward internationalizing counselor education. There have been encouraging but limited developments by the National Board for Certified Counselors (NBCC), ACA, and the Association for Counselor Education and Supervision (ACES) toward this cause. For example, to advance global mental health training and services, NBCC trains and collaborates with international counseling organizations to promote counselor professionalism as they develop their training requirements to the needs of their specific populations. ACA and ACES offer international counseling students and faculty interest networks in which counselors and counselor educators have space to facilitate discussions about challenges and solutions when providing global counseling services and preparing culturally responsive training curricula for students. However, the effect of these advocacies on internationalizing counselor education has not been widely evaluated yet. It appears that the counseling profession recognizes the benefits of this endeavor but is sorting out opportunities as well as resources necessary for implementation. We view contributing to the dialogue on internationalizing multicultural counseling training through an intersectional and social construction online pedagogy as a privilege.
Intersectional and Social Construction Online Pedagogy
An area of dissonance for international counseling students involves differences in cultural worldview. Marsella and Pederson (2004) posited that “Western psychology is rooted in an ideology of individualism, rationality, and empiricism that has little resonance in many of the more than 5,000 cultures found in today’s world” (p. 414). Ng and Smith’s study (2009) highlighted that international students, particularly those from non-Western nations, may struggle with integrating Eurocentric theories and concepts into the world they know. Their findings indicated that international trainees tend to experience more difficulties in areas related to clinical training and worldview conflicts in understanding mental health treatment compared to their domestic peers. International students can find that materials learned in Western-based counselor education have little relevance and applicability to the local demographics in which they work (Ng et al., 2012).
Ng and colleagues (2012) indicated that the goals of internationalizing counseling preparation curricula are to better equip students with required knowledge, awareness, skills, beliefs, and attitudes and to train students to become social change agents who actively resolve global mental health issues and inequalities. Herein lies the opportunity for counselor educators to intentionally search for appropriate pedagogies and to critically present readings and other media that help inculcate a multicultural perspective (Goodman et al., 2015) that is relevant to local contexts while appreciating a global perspective of lived experience and civilization. Social constructionism demands that we take a critical stance toward ways of understanding the world (Burr, 2015). It emphasizes the need to acknowledge the context and extent of subjectivity infused into what we know and invites us to critically examine the knowledge we have gained based on the culture and society surrounding the time period in which we exist. This lens helps us recognize that our knowledge is rooted in historical and cultural relativity and is socially created (Young & Collin, 2004). We need to be mindful that the knowledge created in the classroom has a social, cultural, and political impact on society. Thus, to internationalize distance counselor education, we consider it crucial for academics to recognize the social construction of the knowledge they carry and communicate in the virtual classroom setting, including the construction of their teaching methods for delivering knowledge (hooks, 1994).
Over 30 years ago, Crenshaw (1989) and hooks (1984) postulated that individuals hold a set of multiple and simultaneous identities. Crenshaw introduced the term intersectionality to describe individuals’ complex identities as opposed to categorical generalizations. Traditionally, multicultural courses tend to focus on one aspect of social identity and related oppressions separately from other social identities. The intersecting complexities among social identities and structural oppressions and privileges are often neglected. Collins (2000) provided a pedagogic conceptual framework to include both advantaged and disadvantaged identities. Although the intersectionality theory has been integrated within multiple disciplines, such as women’s studies, sociology, psychology, and law, instructors often do not incorporate intersectionality into diversity courses (Dill, 2009). Scholars, therefore, have called for an intersectional approach to transform higher education (Berger & Guidroz, 2009) and move beyond single-axis models.
To move beyond the individual and monocultural level, Case (2017) proposed that educators and students can address issues of culture, diversity, and advocacy in a diverse classroom through an intersectional pedagogy. Case emphasized an effective intersectional pedagogy that includes the following main tenets: Instructors (a) conceptualize intersectionality as a complex analysis of privileged and oppressed social identities; (b) teach intersectionality across a wide range of institutional oppression; (c) aim to explore invisible intersections; (d) include aspects of privilege and analyze power when teaching about intersectionality theory; (e) encourage students reflection about their own intersecting identities; (f) reflect the impact of educators’ social identities, biases, and assumptions on the learning community; (g) promote social action; (h) value the voice of marginalized students; and (i) infuse intersectional studies across the curriculum.
We believe that using an intersectional perspective that couples with a social construction perspective in multicultural education curriculum development can be valuable in the context of distance international counselor education, particularly in multicultural and international online education that contains a globally diverse student body. By implementing an intersectional and social construction pedagogical design in multicultural and social justice online counseling courses, instructors focus on examinations of social locations concerning privilege and oppression (Cole, 2009) and avoid overemphasizing any single characteristic of individual identities (Dill & Zambrana, 2009). This approach also provides instructors and worldwide students with a critical framework for analyzing structural power and oppression, examining the complexity of identities, and discussing action plans for empowerment and advocacy (Dill & Zambrana, 2009; Rios et al., 2017). Chan et al. (2018) also supported embodying an intersectional framework in developing multicultural and social justice courses within the counselor education curriculum. Counselor educators who teach beyond multicultural counseling knowledge and skills can enhance students’ critical thinking, case conceptualization skills (Chan et al., 2018), and cultural empathy (Davis, 2014) toward marginalized groups. Moreover, students are likely to see beyond the prescriptive counseling approach that addresses a limited set of cultural values (Chan et al., 2018). This perspective also can engage students in analyzing issues of privilege, power, and global oppression, and systematically reflecting on their own experiences.
Wise and Case (2013) noted that intersectional pedagogy is an inclusive approach that helps students reduce resistance when engaging in examining privileged and oppressed identities. This approach validates worldwide students’ various experiences and includes exploration of invisible interactions when discussing personal privilege. Considering that issues related to multiculturalism can evoke various emotions in the classroom, such as frustration, shame, guilt, and defensiveness, intersectional pedagogy provides an outlet to engage all students in this learning process (Banks et al., 2013; Wise & Case, 2013). Creating a safe space for learners in virtual classrooms to bravely experience and address these challenges requires thoughtful learning strategies. Accordingly, we illustrate intersectional and social construction pedagogy and strategies that counselor educators can consider integrating into online curricula to facilitate and assess global students’ multicultural and social justice counseling competencies, as well as provide supports for students in a diverse online learning environment.
Internationalizing an Online Multicultural Counseling Course
The master’s counseling program at the first three authors’ institution offers online or residential format options. The online counseling program provides domestic students and international students who live abroad opportunities to receive counselor education and training. Given the high ratio of international students and students with diverse backgrounds at the authors’ institutions, we believe that structuring the virtual multicultural counseling course from a global perspective and grounding it in a socially constructed, intersectional framework can facilitate student understanding and appreciation of multiculturalism, diversity, and social justice. Additionally, a successful integration of technology entails careful consideration of course content, the instructor’s role in the teaching and learning process, and students’ access to and comfort with the technology (Zhu et al., 2011). The following is an example of how an online master’s-level multicultural counseling course is delivered through an intersectional and social construction pedagogy that includes an international perspective, and how global students’ multicultural and social justice counseling competencies are assessed.
Our online multicultural counseling course focuses on creating a critical space where students can actively and transparently deconstruct their socially constructed knowledge, beliefs, and biases about differences and others. Rather than focusing on attending to specific cultural groups, which historically has been the norm for multicultural counseling classes, we focus on internationalizing the counseling profession and emphasize the need to address cross-national multicultural competencies. This course aims to develop students’ consciousness about the system of oppression that significantly impacts both dominant and marginalized groups’ well-being. Thus, the intersectional and MSJCC frameworks are used to structure our online multicultural counseling course in that knowledge, awareness, skills, and advocacy are at the core of each of the assignments, readings, and synchronized and asynchronized discussions.
Readings assigned for the class include both a clinical counseling textbook that attends to assessment, counseling, and diagnosis from a multicultural lens, and supplementary readings from the fields of multicultural and social justice education. Instructors use a learning management system to facilitate asynchronized online discussion board activities and readings and provide written, audio, or video feedback on students’ assignments. In addition to asynchronized learning, instructors and students meet in an interactive synchronized virtual classroom weekly for 1.5 hours over an 11-week course. Research shows that online models can be effective, with synchronous online programs being the most promising (Siemens et al., 2015). Students also have opportunities to do live multicultural role-plays in which instructors provide immediate feedback.
Instructors can face unique challenges in teaching and discussing some sensitive and controversial issues with students, which is an inherent part of multicultural and social justice advocacy training. It is recommended that educators foster positive relationships with students and establish a safe and trusting learning environment to engage students in constructive conversations and self-reflection (Brooks et al., 2017). Yet teaching a multicultural counseling class in a virtual setting can add additional barriers to fostering a safe learning environment. For example, in a virtual classroom, instructors are only able to see a student’s face amidst many other digital faces. As a result, some of the challenges of teaching this course virtually include effectively noting students’ nonverbal communications, sensing their emotive responses or reactions to the discussion content, and attending to topics that students may be having a difficult time speaking about in front of a large group. Moreover, many videoconferencing platforms allow students to engage in both private and public conversations with other students via chat boxes. Consequently, establishing virtual classroom ground rules is essential. Examples of ground rules and strategies that ensure a safe and respectful online learning environment may include: (a) turning on the camera to allow instructors and classmates to observe others’ nonverbal communication and address immediacy, (b) using headphones to respect classmates’ sharing, (c) turning off the private chat setting to avoid side conversations among students, and (d) providing options for students to share their thoughts and feelings in the chat box. It also is important to facilitate a discussion with students about ways to share their airtime with classmates in a virtual classroom and provide their classmates with understanding and support by observing virtual verbal and nonverbal communication.
To assess global students’ cross-national multicultural and social justice counseling competencies, we developed three major assignments and assessments for this class. Virtual classroom discussion is an essential assessment. To socially construct students’ knowledge of power, privilege, and oppression and reflect students’ learning experience, students are encouraged to actively share their reactions to the learning materials and how these materials are related to personal experience and counseling implications in their countries. Students’ level of participation and self- and other-awareness can be assessed in breakout rooms as well as in a large discussion group. However, considering students may have various ways to engage with the materials, instructors encourage students who struggle with verbally participating in the virtual classroom to collaboratively identify alternative concrete methods to evidence participation with instructors, such as reflective journals.
The second assignment is a group presentation that attends to manifestations of oppression within systems. The purpose of this assignment is to increase global students’ knowledge and understanding of how racism and oppression are produced and reproduced across generations, institutions, and countries. Although oppression impacts all institutions, this project encourages student groups to focus on dynamics in eight mutually reinforcing areas: housing, education, immigration, the labor market, the criminal justice system, the media, politics, and health care. Students are also asked to create a vignette based on the presented topic and facilitate role-plays. This experiential activity facilitates students’ understanding of intersecting identities in the counseling relationship and enhances cross-national cultural empathy by attending to clients’ experience. This assignment increases global students’ awareness of the complexity of mental health issues and transgenerational trauma that can ensue as a result of systematic oppression. It also challenges unconscious biases and beliefs that students may have around marginalized populations being impacted by these systems in their countries.
The last major assignment, the resistance project, is a quarter-long individual project and targets an increase in awareness of self. For counselors, awareness of self in the context of culture is one of the more challenging parts of our work and is a process that is ongoing and constant. This assignment focuses on attending to both conscious and unconscious biases to groups of people. Initially, students are asked to identify three specific cultural groups to which they identify resistance in their countries. Students can express significant struggles around this part of the assignment indicating feelings of guilt, shame, judgment of self, denial of bias, and confusion around their biases. Normalizing and validating these feelings is crucial in fostering a space for critical reflection, as well as providing non-judgmental feedback regarding their initial explorations. The next part of our resistance project asks students to select one of the three identified groups to explore in greater detail throughout the quarter. Students are asked to begin looking for numerous academic sources, social media sources, and immersion experiences that they can engage in throughout the quarter that would encourage them to very directly examine their biases. Significant levels of discomfort appear here among students, particularly regarding individual and group experiences they have engaged in. Students are asked to reflect on and lean into that discomfort in order to better understand it. In addition, they are asked to critically examine their internal process and connect their reactions back to their identified resistance.
Supporting Globally Diverse Students Outside of the Virtual Classroom
As counselor education focuses on further developing multicultural online pedagogy, there is a need to evaluate programmatic effectiveness in demonstrating sensitivity to the concerns of globally diverse student populations. Just as it is critical for instructors to attend to creating culturally relevant curricula, program administrators need an understanding of the challenges that characterize distance students from global communities and be intentional about addressing some of those challenges. This section discusses ways that institutions can walk the walk in their application of the principles espoused in curricular pedagogy by creating an environment in which worldwide students feel welcomed and supported.
According to the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2016), approximately 32% of students enrolled in counseling programs are from racially diverse heritages. Kung (2017) reported that “in the 2015–2016 academic year, over 1 million international students were reported as studying at U.S. colleges and universities” (p. 479). Currently, there are no official statistics on the number of students enrolled in distance counselor education programs by race, ethnicity, or country of residence. Although specific data is lacking, the statistics above provide an indication of the potentially significant presence of an international student population in distance learning programs. It is critical to examine the criteria for determining a university’s effectiveness in supporting worldwide students outside the virtual classroom. “Exemplary institutions” in recruiting and retaining minority students of color have the characteristic of being successful in increasing enrollment of minority students of color and retaining students through to graduation (Rogers & Molina, 2006). While an institution’s effectiveness in providing needed support does not necessarily equate to its ability to retain students and achieve high graduation rates, one can surmise that some unsupported individuals will choose to drop out. Although there are numerous ways that an institution can provide a sustainable environment for global students outside of the virtual classroom, we will focus on six key approaches, namely technology, field experience, multiculturally oriented student support services, mentorship, student-centered multiculturally based organizations, and multiculturally based events and workshops.
In an online education format, access to reliable technology is imperative to students’ success in the program. Level of access to proper computing devices or to the internet by various social identity groups can create a digital divide, which disadvantages one group over another (Bolt & Crawford, 2000; Clark & Gorski, 2001). International students from developing and underdeveloped nations experience frequent disruption when accessing virtual class meetings and course contents because of political causes or technological deficiency in their regions. For example, a student from the Central African Republic is sometimes unable to log in to class meetings when she is unable to turn on generators in a remote village for fear that this could alert guerilla gangs and prompt additional warfare. A student in Peru who does her internship in rural areas is unable to submit her assignments on time because of a lack of internet access. Students in Beijing experience tight internet firewalls preventing them from accessing sites such as Google, Gmail, and YouTube; this problem intensifies during the week of the governmental National People’s Congress annual meetings. Therefore, Clark and Gorski (2001) urged educators to critically analyze the use of the internet as an educational medium and examine ways technology “serves to further identify social, cultural, educational ‘haves’ and ‘have-nots’” in educational settings (p. 39).
As a partial solution to the problem of Chinese students’ difficulty in accessing web-based course content, our institution has purchased a VPN with a reliable server based in Hong Kong. Given that there are approximately 30-plus China-based students in matriculation at our institution each year, this becomes an institutional business decision. Additionally, academic advisors encourage Chinese students to approach their instructors at the beginning of each term to discuss a plan for accessing course material and timely submission of assignments. Instructors and administrators also have a responsibility to be proactive in collaborating with these students in finding alternatives by inquiring and learning about students’ potential challenges regarding technology. Educators need to discuss a plan to accommodate students’ needs within reason.
Issues with cultural worldviews and contextual differences become prominent during students’ process of searching for practicum opportunities and experiences of participating in clinical training in their home countries. Specifically, students and educators have encountered these obstacles in three aspects. First, the philosophical understanding of the purpose of internship and supervision of interns are different. Next, the integration of Eurocentric theories and implications with their clients’ cases might not be applicable. Last, there is a lack of regulatory infrastructure to guide and oversee the helping profession. A case example is students in China, where many native organizations expect to benefit financially from placement of interns. They do not seem to consider that student interns are capable of counseling clients under proper supervision. Thus, many mental health agencies do not permit trainees to provide counseling before graduation. Supervision is considered more of a business arrangement than a supervisory and mentoring relationship.
The first three authors’ institution offers an online practicum course each academic term for students residing and doing an internship overseas. This strategy aims to provide a weekly forum where students receive additional support in applying counseling concepts and approaches to their cultural context. This also serves as a supportive distance environment in which instructors and students collaboratively conceptualize and explore treatment approaches that are culturally and contextually relevant to their client populations. The second purpose for the dedicated practicum course is to navigate students’ dual legal and ethical milieus. A lack of regulatory oversight for the counseling profession in China and other countries has created legal and ethical challenges for intern placements. This reality has added confusion and inconsistencies in what is permissible based on U.S. regulatory and accreditation boards, as well as common practices in students’ home countries.
Multiculturally Oriented Student Support Services
Student services offices in institutions generally provide a wide range of services. To meet distance learners’ needs, it is necessary to implement some student services via an online format. First, institutions provide tutoring services to help improve the English writing skills of speakers of other languages. Students from immigrant and refugee communities as well as some international students fall into this category. Students from non–English-speaking countries enrolled in counseling and related disciplines tend to experience challenges related to English proficiency (Ng, 2006). As such, one-on-one tutoring is available at our institution for students who struggle with editing and American Psychological Association (APA) style writing. This service is critical because many foreign countries do not utilize APA format, and therefore international students do not have familiarity with this style of writing.
Second, tutors at the first three authors’ institution are doctoral students from the psychology department who have opportunities to provide services for students from marginalized communities. Through collaboration between the office of student services and the counseling department, this strategy serves as an excellent service learning experience in working with individuals from globally diverse communities. With an intentional design, the writing skills tutoring service complements classroom pedagogy on multiculturalism by presenting experience with real-world problems, providing opportunities for students to grapple with their beliefs and biases and involve action-oriented solutions.
Mentorship is a substantive resource for supporting worldwide students from diverse communities. Rogers and Molina’s (2006) study found that nine of the 11 psychology programs and departments that were successful at recruiting and retaining students of color had established mentoring programs. In general, ethnic minority students tend to prefer and report more satisfaction with mentors who share a similar racial background (Chan et al., 2015). Figueroa and Rodriguez (2015) posited that mentoring is social justice work that “is a racially and culturally mediated experience instead of a race-neutral, objective interaction” (p. 23). It is an unfortunate reality of counselor education that there exists a significant underrepresentation of minority faculty. The disparity is prominent among Hispanic/Latinx demographics, where student enrollment (8.5%) is almost double the number of faculty (4.7%) from Hispanic/Latinx heritage among CACREP-accredited programs (CACREP, 2016). Black student enrollment is 18.3% and only 12.7% of the total faculty members in CACREP-accredited programs are Black. Chan and colleagues (2015) suggested that in the absence of same-race mentors, the presence of cross-cultural support in the form of multiculturally sensitive mentoring can be beneficial and even critical to the success of international students from diverse ethnic backgrounds.
To support the unique needs of international students in the residential and online cohort, the first author designed weekly office hours for online international students to provide advising and mentorship. The virtual office hours aim to provide a space where students and their peers can not only share challenges, struggles, and concerns about their learning experiences in the program, but also support each other. Additionally, the third author and a colleague have served as international and distance directors of clinical training, which can provide specific mentorship regarding practicum experiences for international students.
Student-Centered Multiculturally Based Organizations
The presence of student-centered organizations is another effective way to provide a sense of belonging and an environment that facilitates peer support among those with shared interests on campus (Rogers & Molina, 2006). Some culturally and social justice–based organizations active at the first three authors’ institution serve this purpose well. One of the university-wide organizations, Diaspora, serves students, staff, and faculty in the community who are interested in learning about and advocating for mental health issues relevant to the Black diaspora. Members of Diaspora aim to raise the community’s awareness of psychosocial and environmental factors that impact the Black community’s well-being. Another organization at our institution, the Latinx Task Force, was formed with a Unity grant award from our university president’s office for faculty, students, and staff to join forces across programs to implement projects that serve the Latinx/Hispanic community on and off campus (Latinx Task Force, n.d.). Furthermore, the Latinx Task Force initiated a Spanish clinician course that introduces students to essential clinical vocabulary, clinical skills, and cultural considerations required to work with Spanish-speaking clients. The Latinx Task Force also conducts a mentorship series that brings Latinx professionals in the field to offer career mentoring support to students.
Multiculturally Based Events and Workshops
Delivery of multicultural education and inclusion of diverse students should not be limited to the virtual classroom. Institutions can be intentional in hosting events and workshops that complement and reinforce classroom pedagogy on multiculturalism while actively supporting individuals from various communities. In recent years, the first three authors’ institution has hosted a rich array of workshops with topics such as “LGBT Psychology,” “Asian Americans and Suicide,” and “Risk and Resiliency Among Newcomer Immigrant Adolescents.” In addition, a “Women of Color Leaders in Psychology” event celebrates the contributions of women of color in psychology and social justice. When the workshops occur in our physical venue, they are often made accessible via videoconferencing platforms and are recorded for later viewing at a convenient time or by those in a different time zone.
Multicultural counseling education and support of the globally diverse student population are ongoing, interrelated endeavors that extend beyond the virtual classroom walls. Intentionality in hosting extracurricular events and creating a supportive environment are ways an institution makes multicultural pedagogical concepts come alive for students. They also are a way of sustaining worldwide students to graduate with a strong foundation from which to launch their counseling careers.
Discussion and Future Direction for Research
The multicultural counseling course in counselor education programs is one of the critical spaces where global students actively engage with the core components of the MSJCC. Given the complexity of teaching this course in a distance learning format, it is crucial for educators to thoroughly think through the varying foundational components, including structure, content, pedagogy, and the various challenges that can arise in virtual classrooms.
We have used our experiences in integrating technology into the multicultural counseling curriculum to discuss online pedagogical framework and virtual course development while exploring unique opportunities, challenges, and solutions. Given the movement of internationalizing the counseling profession, we postulate that multicultural counseling distance education must extend beyond U.S. borders, class meetings, and the curriculum. It is critical that counselor educators provide multicultural and social justice counseling training through systemic modeling by internationalizing the curriculum and training environment and collaborating with training programs and institutions to advocate for, attend to, and support the needs of globally diverse students in distance education.
Currently, the literature on training and online delivery of international multicultural counseling education remains limited. To explore the best online pedagogy for internationalizing multicultural counseling education, more research is needed. As such, future research could focus on examining the outcome of incorporating intersectional and social construction approaches in online counseling curricula, including global students’ multicultural and social justice counseling competencies in their home countries. Future studies also might investigate different course structures and online pedagogy to understand the best methods for multicultural distance counselor education. There is a need to explore counselor educators’ experiences of conducting online multicultural counseling education with globally diverse student populations and their perspectives on receiving multicultural counseling distance education. Supports needed for global students in the online environment may differ from traditional students. Therefore, research on how the academic support of counseling programs and institutions impacts global students’ counseling practice and retention in distance counselor education can be valuable.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Szu-Yu Chen, PhD, NCC, LPC, RPT, is an assistant professor at Palo Alto University. Dareen Basma, PhD, LPC-MHSP, is a core faculty member at Palo Alto University. Jennie Ju, PhD, LPC, is a core faculty member at Palo Alto University. Kok-Mun Ng, PhD, NCC, ACS, LPC, is a professor at Oregon State University. Correspondence can be mailed to Szu-Yu Chen, 1791 Arastradero Drive, Palo Alto, CA 94304, firstname.lastname@example.org.
Loni Crumb, Natoya Haskins, Shanita Brown
This phenomenological study explored the experiences of 15 professional counselors who work with clients living in impoverished communities in rural America. Researchers used individual semi-structured interviews to gather data and identified four themes that represented the counselors’ experiences using the Multicultural and Social Justice Counseling Competencies as the conceptual framework to identify the incorporation of social justice and advocacy-oriented counseling practices. The themes representing the counselors’ experiences were: (1) appreciating clients’ worldviews and life experiences, (2) counseling relationships influencing service delivery, (3) engaging in individual and systems advocacy, and (4) utilizing professional support. The counselors’ experiences convey the need to alter traditional counseling session delivery formats, practices, and roles to account for clients’ life experiences and contextual factors that influence mental health care in rural, impoverished communities. Approaches that counselors use to engage in social justice advocacy with and on behalf of rural, impoverished clients are discussed.
Keywords: rural, impoverished communities, advocacy, social justice, multicultural
Approximately 41.3 million Americans live in poverty (Semega, Fontenot, & Kollar, 2017) and consistently face multiple chronic stressors (e.g., food and housing insecurities, social isolation, inability to access adequate physical and mental health care) that impact their quality of life (Fifield & Oliver, 2016; Hill, Cantrell, Edwards, & Dalton, 2016). Nevertheless, the scope of mental health concerns of individuals and families residing in persistently poor, rural communities remains under-researched and overlooked by the public, scholars, and policymakers (Tickamyer, Sherman, & Warlick, 2017). Furthermore, advocacy efforts that foster social and economic justice and support the mental health of persons living in rural poverty warrant further advancement.
Scarce availability of mental health care services, ineffective modes of treatment and interventions, and mistrust of mental health care professionals contribute to the low utilization of mental health care services among persons living in rural poverty (Fifield & Oliver, 2016; Imig, 2014). Consequently, there are few evidence-supported culturally relevant mental health interventions tailored to address the specific needs of people living in rural poverty, particularly with a focus on social justice advocacy (Bradley, Werth, Hastings, & Pierce, 2012; Imig, 2014). Counselors practicing in rural, impoverished areas must be prepared to address systems of oppression, discrimination, marginalized statuses, and the impact these factors have on counseling services and clients’ well-being (Grimes, Haskins, & Paisley, 2013; Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016). Moreover, according to the 2016 Code of Ethics from the National Board for Certified Counselors (NBCC) and the 2014 ACA Code of Ethics from the American Counseling Association, counselors are expected to take actions to prevent harm and help eradicate the social structures and processes that reproduce mental health disparities in vulnerable communities (ACA, 2014; NBCC, 2016). In recognition of this expectation, the Multicultural and Social Justice Counseling Competencies (MSJCCs) were developed to guide mental health counselors toward practicing culturally responsive counseling and incorporating social justice advocacy initiatives into the process (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015). Thus, the MSJCCs’ framework undergirds our examination of counselors’ experiences and clinical practices that support the mental health and well-being of clients living in poverty in rural America.
Understanding Rural Poverty and Mental Health Care
When discussing literature pertaining to rural poverty, it is important to first define relevant terms. The U.S. Department of Agriculture’s Economic Research Service (USDA; 2017) defines poverty as having an income below the federally determined poverty threshold. For example, the 2017 poverty threshold for an individual under 65 years of age was $12,752, and the poverty threshold was $16,895 for a household with two adults under age 65, with one child under 18 years of age (USDA, 2017). Persistently poor areas are defined as communities in which 20% or more of the population has lived below the poverty threshold over the last 30 years with low populations (fewer than 2,500 people; USDA, 2017). The majority of persistently poor communities are located in rural Southern regions of the United States (USDA, 2017). Rural communities that experience persistent poverty have had little diversification of employment, are underserved by mental health care providers, and lack affordable housing and economic development (Tickamyer et al., 2017). For the purposes of this study, the definitions described above were used to define and understand rurality and poverty.
Mental Health Care in Rural, Impoverished America
An abundance of literature exists that identifies concerns related to mental health care for people who live in rural poverty (Reed & Smith, 2014; Tickamyer et al., 2017). For example, Snell-Rood and colleagues (2017) conducted a qualitative study that explored the sociocultural factors that influence treatment-seeking behavior among rural, low-income women. Participants reported that the quality of counseling in their rural settings was unsatisfactory because of counselors recommending coping strategies that were “inconsistent” with daily routines and beliefs (Snell-Rood et al., 2017). Alang (2015) conducted a quantitative study that investigated the sociodemographic disparities of unmet health care needs and found that men in rural areas were more likely to forgo mental health treatment because of gender stereotypes. Specifically, Alang found that men were encouraged to ignore mental health concerns and avoid help-seeking behaviors. Furthermore, children living in rural poverty have fewer protective resources and less access to services that can address their needs and are subsequently exposed to increased violence, hunger, and poor health (Curtin, Schweitzer, Tuxbury, & D’Aoust, 2016).
Adults and children living in rural poverty often have lower mental health literacy (i.e., the ability to recognize a mental health concern when it arises and how to cope with one when it occurs; Rural Health Information Hub, 2017). For example, researchers (Pillay, Gibson, Lu, & Fulton, 2018) examined the experiences of the rural Appalachian clients who utilized mental health services and found that clients were ambivalent about diagnoses and suspicious when providers suggested psychotropic medications to support treatment. Likewise, Haynes et al. (2017) conducted focus group interviews that included persons living with a mental illness, health care providers, and clergy living in rural, impoverished communities in the Southern United States, and reported a general lack of awareness about mental illness. The researchers suggested that individuals have less knowledge of what mental illness looks like, how to recognize it, and how to identify warning signs of crises in Southern rural, impoverished communities (Haynes et al., 2017). As a result of less mental health literacy, people in rural low-income communities may delay seeking counseling treatment until symptoms have intensified and face a greater likelihood of hospitalization related to mental health challenges (Neese, Abraham, & Buckwalter, 1999; Stewart, Jameson, & Curtin, 2015).
Counselor Competence and Poverty Beliefs
Researchers have indicated that mental health professionals practicing in rural, economically deprived areas are not properly trained to address the multiple needs of this population (Bradley et al., 2012; Fifield & Oliver, 2016; Grimes, Haskins, Bergin, & Tribble, 2015). Fifield and Oliver (2016) surveyed 107 rural clinicians, exploring their perceived training-related needs and the pros and cons of rural counseling practice. The researchers found that many counselors did not receive adequate training to work with the population they served, and the counselors did not feel properly prepared to address the host of issues that may arise in their rural practice.
Moreover, mental health professionals continue to hold negative poverty beliefs and social class biases (Bray & Schommer-Aikins, 2015; Grimes et al., 2015; Smith, Li, Dykema, Hamlet, & Shellman, 2013) that negatively impact the quality of services provided. Researchers have shown that some counselors are less willing to work with clients of lower socioeconomic statuses because of communication barriers, having less knowledge of and exposure to the poverty culture, and possessing negative stereotypes about poor, rural populations (e.g., uneducated, dirty, violent, lazy; Bray & Schommer-Aikins, 2015; Smith et al., 2013). Consequently, clients from lower socioeconomic statuses receive more serious mental health diagnoses or are often misdiagnosed, which may be attributed to the professional’s negative biases, as well as lack of adequate multicultural training (Clark, Moe, & Hays, 2017).
Multicultural Counseling Competence
Increased training in multicultural counseling competence has a significant impact on counselors’ poverty beliefs (Clark et al., 2017; Toporek & Pope-Davis, 2005). In a quantitative study examining the relationship between multicultural counseling competence and poverty beliefs using a sample of 251 counselors, Clark et al. (2017) identified that higher levels of multicultural competence and training decreased poverty biases and helped counselors to understand the structural causes of poverty. Similarly, Bray and Schommer-Aikins’ (2015) survey of 513 school counselors found that counselors with training through multicultural courses recognized the external factors that contribute to poverty; however, the study did not focus on effective interventions that counselors utilized with this population.
Although these studies identified that multicultural knowledge and awareness increased counselors’ understanding of the culture of poverty, more research is necessary to explore how this information is applied to provide counseling professionals with evidence-based illustrations of social justice advocacy in practice (Ratts & Greenleaf, 2018). Accordingly, the purpose of this study was to (1) develop an understanding of the experiences of mental health counselors who work in rural, persistently poor communities and (2) identify ways that counselors incorporate social justice advocacy into counseling using the lens of the MSJCCs. The research question guiding this study was: What are the lived experiences of mental health counselors working in rural, persistently poor communities?
The MSJCCs, a revision of the Multicultural Counseling Competencies (Sue, Arredondo, & McDavis, 1992), offer a framework to incorporate culturally responsive counseling and social justice advocacy initiatives into counseling practices, research, and curricula (Ratts et al., 2015). Established in a socioecological framework, the MSJCCs help counselors examine personal biases, skills, and the dynamics of marginalized and privileged identities in relation to multiculturalism and social justice counseling competence and advocacy. Additionally, the MSJCCs assist counselors in acknowledging clients’ intersecting identities, which bestow various aspects of power, privilege, and oppression that may impact their growth and development.
The developmental domains of the MSJCCs—(a) counselor self-awareness, (b) client worldview,
(c) counseling relationship, and (d) counseling and advocacy interventions—help counselors understand social inequalities that are perpetuated by institutional oppression in order to better serve historically marginalized clients (Ratts et al., 2015). Likewise, aspirational competencies espoused in the MSJCCs—namely (a) attitudes and beliefs, (b) knowledge, (c) skills, and (d) action—serve as objectives for multicultural, social justice competence and advocacy interventions (Ratts et al., 2015, 2016). Although the MSJCCs have been identified as goals for all counselors, limited research exists that illuminates the MSJCCs as a framework for understanding social justice applications within rural, high-poverty areas. Therefore, in considering the four distinct developmental domains and aspirational competencies, the authors utilized the MSJCCs as a basis to understand counselors’ experiences in rural, high-poverty communities. For the purposes of this study, social justice advocacy is understood as interventions and skills that counselors utilize to address inequitable social, political, or economic conditions that impede the personal and social development of individuals, families, and communities (Lewis, Ratts, Paladino,
& Toporek, 2011).
University institutional review board approval was granted for this study. We used a descriptive phenomenological qualitative research design, which is suitable for scholars to examine the lived experiences of individuals within their sociocultural context (Creswell & Creswell, 2018; Giorgi, 2009). In descriptive phenomenological studies, researchers use participants’ responses to describe common experiences that capture the “intentionality” (perception, thought, memory, imagination, and emotion) related to the phenomenon under study (Giorgi, 2009). Furthermore, using qualitative research methods allows researchers to provide an in-depth exploration of lived experiences and helps multiculturally competent counselor–researchers highlight gaps in counseling literature and inequities in counseling practices in order to advocate for systemic changes in the counseling profession (Hays & Singh, 2012; Ratts et al., 2015).
Role of the Researchers
We recognize the possibility of bias in empirical research and acknowledge our social locations, identities, and professional experiences in relation to the current research study. All three authors identify as African American women from low socioeconomic backgrounds. We identify as counselor–advocate–scholars (Ratts & Greenleaf, 2018) and incorporate advocacy for underserved populations into our counseling practices, research, supervision, and teaching (Ratts et al., 2015). We bracketed personal thoughts and feelings and discussed biases that may possibly influence the data throughout the study. For example, the frequent criminalization of poverty was a difficult finding to discuss with the participants and we met to express our thoughts regarding this finding. A graduate research assistant (middle class, European American female) was selected to assist in data collection and analysis to increase objectivity in the research process, as she was less familiar with underserved populations, but trained extensively in qualitative research techniques. We acknowledge that we used the developmental domains and aspirational competencies espoused in the MSJCCs to conceptualize this research study, analyze the data, and present the findings and implications to foster positive changes in mental health care for people living in rural, poor communities. Furthermore, it is our view that the data did not emerge independently, but that as researchers we used a rigorous process such as the use of thick descriptions to analyze and identify nuances and commonalities in the data while also accounting for our assumptions and biases (Hays & Singh, 2012; Lincoln & Guba, 1986). Our position as counselor–advocate–scholars helps to bring expertise to our scholarship and practices (Hays & Singh, 2012; Ratts & Greenleaf, 2018).
Fifteen participants (N = 15; 13 women, two men) were selected for the study using purposeful criterion sampling (Patton, 2014). Participants’ ages ranged from 28 to 67 years (M = 40). Twelve participants identified as European American and three as African American. Twelve participants were licensed professional counselors and three were licensed professional counselor associates. Two participants had doctoral degrees in counseling. Participants practiced counseling in various settings such as private practices, colleges, secondary schools, and community counseling centers. Participants also had additional credentials: three were licensed professional counselor supervisors, seven were licensed clinical addiction specialists, one was a certified clinical trauma professional, and one was a registered play therapist. Years of work experience as a professional counselor ranged from 2 to 20 (M = 6.7).
Data Collection and Analysis
Recruitment solicitation flyers were distributed to various mental health agencies located in rural counties designated as persistently poor (USDA, 2017) in one state in the Southeastern United States. The mental health agencies were identified by searching public information websites for counseling and psychological support resources within these counties. Potential participants completed a telephone eligibility screening and a demographic questionnaire. The demographic questionnaire included questions asking potential participants to identify a pseudonym, their age, ethnicity, employment status and location, and professional credentials. Participants who met inclusion criteria (i.e., licensed mental health clinicians currently employed in persistently poor rural locales) were selected to participate in the study. There is no required sample size for phenomenological studies; rather, authors (Creswell & Creswell, 2018; Hays & Singh, 2012) recommended researchers consider the purpose of the research and depth of the data. We continued to recruit participants until saturation was achieved by seeing a recurrence in the data (Creswell & Creswell, 2018; Hays & Singh, 2012). After completing Interview 15, we did not identify novel data and agreed that a sufficient amount of data was collected to provide a comprehensive understanding of the phenomenon under investigation.
The researcher is the key instrument for data collection in qualitative research (Creswell & Creswell, 2018). A graduate assistant and the first author collected all study data by the use of qualitative interviews using an open-ended, semi-structured interview protocol (Hays & Singh, 2012). Each participant completed individual, one-phase, open-ended, semi-structured, face-to-face or live video interviews, lasting approximately 60–90 minutes. We audio-recorded all interviews, and they were transcribed by a professional transcription service.
The 12 interview questions that guided the study were framed by the MSJCCs’ constructs in extant literature related to the experiences of mental health counselors and clients in rural, poor communities (Bradley et al., 2012; Clark et al., 2017; Grimes et al., 2015; Grimes et al., 2013; Kim & Cardemil, 2012) and specific multicultural and social justice counseling constructs espoused in the MSJCCs (Ratts et al., 2015; Ratts et al., 2016). Six questions focused on understanding the participants’ knowledge of rural, poor communities and their experiences. Examples of these questions were: “Can you tell me the influence that persistent poverty has on the services you provide in a rural setting? What personal and client factors or experiences are influential to your work?” and “What is needed for you to competently provide counseling services to this population, if anything?” An additional six questions, also informed by the MSJCCs, sought to further explore the participant’s beliefs, skills, and actions related to multicultural competence, social justice advocacy, and counseling, such as “Can you share with me your definition and understanding of social justice advocacy in counseling? Can you share ways (if any) you incorporate social justice advocacy into your work as a counselor in a rural, economically deprived area?” and “Please share any perceived barriers to engaging in social justice advocacy and counseling in rural, economically deprived areas.”
Analysis of the data was informed by Giorgi’s (2009) and Giorgi, Giorgi, and Morley’s (2017) process for descriptive phenomenological data analysis. Specifically, we adhered to five steps in the data analysis process. First, we assumed a phenomenological attitude, in which we bracketed suppositions that could potentially influence the data and research process, such as our frustrations with perpetual deficit ideology in research related to marginalized populations. Second, after each interview was completed, we individually read each transcript to get a sense of the whole experience (i.e., native descriptions) and wrote brief notes in the margins to pinpoint any significant descriptive statements and expressions (Hays & Singh, 2012). For instance, we notated participants describing specific counseling practices that they believed were related to social justice advocacy as significant descriptive statements. We sent participants a copy of their transcript for member checking. Third, we re-read transcripts to demarcate data into multiple meaning units by clustering the invariant descriptions of participants’ experiences.
Initially, we also used a priori codes based on the MSJCCs to begin to identify units of meaning. For example, codes such as systems, advocacy, self-awareness, community, and collaboration helped us to infuse the MSJCCs’ framework and focus the findings toward understanding social justice experiences. As an example, the recognition and appreciation of a client’s ability to ascertain needed resources despite having less access and the participants’ willingness to assist in resource allocation were two invariant descriptions of experiences. The analysis process yielded 46 initial units of meaning. Participants’ quotes and definitions related to meaning units were contained in a research notebook to manage data and establish consensus coding (Hays & Singh, 2012). We held multiple meetings to discuss if and how these meaning units related to the developmental domains of the MSJCCs. For example, we discussed how one meaning unit, idiosyncrasies in the support system, closely related to the MSJCCs’ client worldview domain and reached a consensus in understanding that the participants’ ability to recognize that their clients had often strained their natural support systems exemplified that the counselor possessed knowledge of how their clients’ economic status and limited support systems shaped their attitudes and engagement in mental health treatment. In our fourth step, we reviewed the data to transform the meaning units into sensitive descriptive expressions that highlighted the psychological meaning of participants’ descriptions. We used free imaginative variation to determine the essence of the phenomenal structures of the participants’ experiences (Giorgi, 2009; Giorgi et al., 2017). We discussed any differences in understanding participants’ invariant experiences. For example, we discussed if the participants’ recognition of their need for a professional consultation to address underdeveloped counseling skills and biases related to the MSJCCs’ counselor self-awareness domain. Finally, we negotiated the interconnections and essential meanings of the meaning units, coalesced the data, and identified four essential structures that represented the descriptions of participants’ experiences and assigned them a descriptive thematic label.
Strategies for Trustworthiness
It is vital that researchers establish criteria for trustworthiness in qualitative research studies (Morrow, 2005). We demonstrated credibility through the use of bracketing, triangulation of the data sources, member checking, and peer debriefing (Morrow, 2005). Participants were provided with a copy of their transcriptions and case displays to review for member checking. We employed triangulation of data by crosschecking data (Hays & Singh, 2012) with the existing empirical studies related to rural poverty and mental health counseling. Data collection and analysis occurred concurrently in order to triangulate findings (Hays & Singh, 2012).
Using an MSJCCs lens, we identified four themes that represented the experiences of counselors who work with clients in rural poverty: (1) appreciating clients’ worldviews and life experiences, (2) counseling relationships influencing service delivery, (3) engaging in individual and systems advocacy, and (4) utilizing professional support. The findings are explicated using participants’ quotes to illustrate the meaning of each theme.
Appreciating Clients’ Worldviews and Life Experiences
Participants in the study described how they developed an appreciation for their clients’ worldviews and life experiences, even if they were different from their own. For example, Jade shared how she gained insight into and showed an appreciation for her clients’ worldviews by “showing empathy, being curious, and asking questions about what it was like for them in certain situations.” Jade expressed that seeking to understand clients’ worldviews was vital when working with African Americans living in rural poverty because she did not have the same experiences. Shelly also conveyed an appreciation for her clients’ worldviews and experiences and the impact on her clinical skills, sharing that she acquired a “different perspective” in her approach by gaining knowledge of her clients’ family structures and listening to their history.
Nine participants described that working in rural, impoverished communities entailed understanding the impact that limited resources have on providing adequate mental health services and recognizing the idiosyncrasies in clients’ support systems. Three participants described how their clients had often “burned” or “exhausted” their natural support system (i.e., personal relationships with other people that enhance the quality of one’s life), which made it difficult for participants to identify persons who would be supportive of their clients in the mental health treatment process. Addie described her counseling experiences in rural, poor communities, stating, “People have so little to fall back on, if they’re chronically mentally ill or they have a family member who is, they’re just out of resources, and they’ve maybe even burned their natural supports.” Addie further elaborated on her experiences, explaining that family members would often not return her phone calls after a client was admitted for inpatient mental health treatment.
Five participants expressed the importance of considering how low mental health literacy and mental illness stigma influenced clients’ knowledge, attitudes, and beliefs toward mental health treatment. Lola explained that she observed low mental health literacy in rural, poor communities: “There is a very low level of understanding with regard to symptoms associated with mental illness.” Lola discussed the prevalence of stigma toward clients with diagnosed mental health disorders as well as toward clients that had not been formally diagnosed because of the limited understanding of mental illness. Likewise Julian, a school-based counselor, expressed the impact of low mental health literacy in rural, high-poverty communities. Julian shared that the majority of her youth clientele were being raised by their grandparents, who had less knowledge of mental health symptoms and treatment; therefore, grandparents were often hesitant to seek mental health treatment services for their grandchildren.
Many (n = 11) of the participants indicated that in understanding the clients’ experiences and worldviews they were able to see how clients managed to be resourceful and resilient when faced with hardships. In illustration, Lola stated, “They are some of the most resourceful and resilient people that I’ve ever met; they have a knack for finding ways to achieve what needs to happen despite not having the typical resources . . . that’s very admirable.” Sue and Brenda expressed similar sentiments, also describing their clients as “resourceful.” In essence, participants explicated their attitudes and dispositions (e.g., recognizing and appreciating clients’ resourcefulness, possessing curiosity, learning about family structure and support systems) in working with clients in rural, impoverished communities. In accordance with the MSJCCs, participants expressed the importance of recognizing how the worldviews and life experiences of their marginalized clients are influenced by the context of rural poverty, such as how low mental health literacy and stigma impact the utilization of mental health treatment for this population.
Counseling Relationships Influencing Service Delivery
Participants (n = 10) described the importance of having a strong counseling relationship when working with marginalized individuals and families living in rural poverty. This solid relationship motivated participants to alter the mode of service delivery or intentionally focus more on client-centered services. Reflecting on her experiences providing home-based counseling services, Sue expressed the importance of building trust and empowerment in counseling relationships, especially when clients were involved with professionals from other agencies (e.g., probation officers) who also visited their homes. Sue described how she reinforced trust and empowerment by telling her clients, “This is about you and I’m walking alongside this path with you, I’m not going to make decisions for you.” Sue expressed that reinforcing empowerment was an essential part of counseling in rural, poor communities because clients often felt as if their power has been taken away.
Other participants shared that many of their clients came to counseling sessions without their basic needs met (e.g., food, housing, and safety) and that a solid counseling relationship allowed for more trust and openness. In return, participants expressed that clients were more willing to express their need for basic necessities without feeling ashamed, and that they often altered their services to assist clients in ascertaining immediate resources. For example, Heather noted that the poverty level was so low in her community that many of her youth clients’ basic needs were not being met and they would ask her to stop and purchase them meals. Heather disclosed that she often responded by stating, “Okay, we’re going to have to change where we’re providing therapy today, or maybe how therapy’s going to look today” to accommodate their needs. Similarly, Sadie shared, “It’s hard to see your clients going without things that you would consider basic.” Sadie described circumstances in which she arranged for food to be dropped off to the school and picked up by her clients.
Che and eight other participants acknowledged that having strong counseling relationships with clients living in rural poverty increased their willingness to extend their services beyond traditional counseling roles and settings. The participants described various cases in which they assisted clients in securing food or housing, or navigating Medicaid and other entities. For example, Che shared that she attended a mental health disability hearing with her client in which she was allowed to speak on the behalf of a client who experienced severe social anxiety. Additional participants described ways they broadened their roles to include consulting and case management and provided examples of ways they altered counseling sessions (e.g., including children because clients had no childcare) or offered incentives for attendance (e.g., bus passes and toiletries) to support clients’ continuity in treatment as well as using these as a means to help meet clients’ imminent needs. Overall, participants conveyed that their counseling relationships allowed for trust and flexibility that enabled them to use ancillary skills and knowledge when working in rural, persistently poor communities, such as skills in crisis management or intentionally building resource networks with medical professionals, churches, social service providers, law enforcement, and community organizations to help meet clients’ basic needs.
Engaging in Individual and Systems Advocacy
All participants reported engaging in various individual and systems advocacy interventions when working in rural, impoverished communities. Participants shared that engaging in advocacy was necessary, ranging from their initial sessions with their clients until termination and follow-up. George shared that he started advocacy initiatives in the initial assessment by “not jumping to assumptions” and spending more time observing clients and exploring their history. He stated that he acknowledged if clients were already taking steps toward positive change to encourage self-advocacy. George explained, “I think the most direct thing that I can do is to empower people to recognize their strengths and their rights.” Similarly, Jade shared, “I use motivational interviewing with clients to help them become better advocates for themselves.” Other participants expressed that promoting self-advocacy was vital for this specific population because of the high probability that a client would not return to counseling because of barriers related to transportation, finances, and stigma. Seven participants shared that it is important to have personal knowledge of systems that affect the client in order to inform advocacy interventions. Renee mentioned, “With all the Medicaid changes . . . I’ve got to take every client into a financial conversation. . . . So keeping myself educated . . . I can be a voice of support to them and have an understanding if they come to me.”
Additionally, participants reported various situations in which they engaged in advocacy interventions outside of the office setting. Two participants shared that they engaged in advocacy with and on behalf of clients to help them navigate the criminal justice system. For example, Jade advocated on behalf of a teenage client to law enforcement officials to request the removal of her client’s ankle monitor, which she believed was not necessary. Heather shared that she wrote letters to the courts on behalf of her clients.
Participants also discussed their involvement with helping clients sustain housing. Che shared, “I’ve spoken up for my clients against landlords who were trying to railroad several of my clients with their rent, and one in particular was trying to charge my client double the rent.” Similarly, Jade shared, “I was able to advocate to my supervisors to get funds to help pay the past bills so [clients] could move into a new location and not lose housing.”
Four participants conducted trainings in schools and within the community to inform others of culturally responsive practices with people living in rural poverty. Sadie shared that she provided educational workshops to school counselors, administrators, and teachers to help them understand the life experiences of individuals and families living in rural poverty. Sadie explained that she educated her colleagues on the effects of generational poverty and helped them to explore ways they could use various educational strategies for clients in these circumstances. Overall, counselors recognized clients’ needs and engaged in an array of advocacy interventions individually with clients, as well as in the community to support clients’ continuation in treatment, link clients to services, or help clients allocate resources in rural, poor communities.
Utilizing Professional Support
Some participants (n = 6) were the only mental health providers in the communities in which they worked. Thus, they spoke of instances of feeling frustrated because of the lack of resources for clients, role overload, and inability to connect with other counselors. Participants expressed that support from other professionals in the behavioral health field was helpful to alleviate frustrations. With this awareness, participants shared that conversations, consultations, and formalized supervision sessions were useful to explore their biases and feelings of hopelessness, to address compassion fatigue, and to learn new clinical interventions. For example, Blaze shared that formalized supervision was beneficial to increase his knowledge and improve his attitude about working in rural, impoverished communities. He stated, “The people who have supervised me understand that I’m coming from a different area and this is all kind of a learning curve. They’ve been good about helping me acclimate to the area.” Similarly, eight participants shared that ongoing supervision was helpful to abate adopting negative stereotypes and to address de-sensitization to clients’ needs, particularly when seeing clients who perpetually faced hardships. Lola discussed the benefits of having a professional support system among her colleagues to manage the demands of counseling in rural poverty. She stated, “We support each other personally when professional issues begin to impact our personal lives.” Furthermore, Lola described that ongoing supervision was “very helpful and necessary” as it provided her the opportunity to “check in” with herself and assess how she was managing the demands of her work.
Seven participants shared that receiving professional support reinforced ongoing self-awareness. For example, Sadie stated, “I think [it’s important] being willing to recognize that I’m not perfect . . . being willing to say here’s a place where I need to improve.” Sadie also expressed that it was important for her to seek supervision or personal mental health services to not allow her personal frustrations to “bleed over” into her client sessions. Likewise, Jade explained that supervision and taking continuing education credits regarding cultural differences were optimal to her success. In alignment with the constructs in the MSJCCs, the participants acknowledged the importance of engaging in critical self-reflection to take an inventory of their skills, beliefs, and attitudes (Ratts et al., 2016) that impact the services they provided to marginalized clients living in rural poverty. Overall, seeking ongoing supervision and engaging in professional development activities were necessary to prevent adopting stereotypes and to continue advocacy efforts.
Using participants’ voices and the lens of the MSJCCs, we illuminated the essence of providing mental health counseling in rural, persistently poor communities. The participants described the importance of showing an appreciation for clients’ worldviews and life experiences and how their counseling services encompassed varied approaches to service delivery and non-traditional counseling methods to engage rural, impoverished clients in the treatment process. Participants frequently engaged in individual and systems advocacy with and on behalf of their clients and described how having professional support was necessary to provide culturally responsive mental health counseling in rural, persistently poor communities. The findings serve as the basis for the following discussion.
This study explored the experiences of mental health counselors working in rural, impoverished communities and identified ways counselors incorporated social justice advocacy using the lens of the MSJCCs to identify advocacy skills and interventions. We found that counselors who work with clients in rural poverty appreciate their clients’ worldviews and life experiences, value their counseling relationships, alter service delivery formats, engage in advocacy, and seek ongoing professional support and development opportunities. Specifically, the first theme captured how counselors in the study expressed an appreciation for their clients’ worldviews and life experiences, as described in the MSJCCs’ client worldview domain. Counselors recognized that various contextual factors, such as family structure, nuances in the natural support systems, less access to resources, as well as how race and social class status shaped their clients’ worldviews, influenced their utilization of mental health treatment. This finding lends support to previous literature associated with examining how economic disadvantages and rurality influence mental health care services and literacy (Deen & Bridges, 2011; Kim & Cardemil, 2012). Consistent with the MSJCCs’ (Ratts et al., 2015) client worldview domain, the counselors explored and appreciated clients’ history and life experiences, and acknowledged the clients’ “resourcefulness” as a strength.
Furthermore, counselors in the study expressed a willingness to engage in their clients’ personal communities, which aligns with the suggestion in the client worldview domain that counselors should immerse themselves in the communities in which they work to learn from and about their clients (Ratts et al., 2015). The findings from the study correspond to previous research that examines how counselors with increased exposure to individuals living in poverty have enhanced multicultural competence and are able to critically examine systemic or structural factors that contribute to the underutilization of mental health services in high-poverty communities (Clark et al., 2017).
The second theme, counseling relationships influencing service delivery, reflected the MSJCCs’ counseling relationship domain. Participants recognized that their clients’ ability to engage in the traditional therapeutic process was often thwarted because many of their clients’ basic needs were not met. As implied in the counseling relationship domain, counselors are advised to utilize culturally competent assessment and analytical and cross-cultural communication skills that allow them to effectively determine clients’ needs and employ collaborative, action-oriented strategies to strengthen the counseling relationship (Ratts et al., 2015).
Reflective of this domain, counselors in the study often altered service delivery formats and assumed alternative roles to meet clients’ needs. The current findings offer support for research that advances increasing flexibility in counseling roles and culturally competent assessments when working in marginalized communities (Fifield & Oliver, 2016).
Another distinctive finding of this study was encompassed in the third theme, which captured the MSJCCs’ counseling and advocacy interventions domain, and illuminated the participants’ use of strategies to promote continuation of services (e.g., home-based counseling, group formats with the inclusion of childcare, and distributing incentives) as well as advocacy interventions to address clients’ imminent needs. Expanding previous research that illuminated the role of self-advocacy (Singh, Meng, & Hansen, 2013), the participants expressed the importance of engaging in intrapersonal, interpersonal, and institutional advocacy interventions with and on behalf of clients, such as assisting clients in securing or maintaining housing, acquiring supportive educational resources in school settings, rebuilding familial relationships, and preventing the criminalization of poverty. Although these findings are similar to previous researchers’ perspectives that suggest that counseling in rural poverty requires counselors to engage in various advocacy roles (Kim & Cardemil, 2012; Reed & Smith, 2014), this study answers the call to provide practical examples of incorporating social justice advocacy into counseling with historically marginalized populations (Ratts & Greenleaf, 2018).
The final theme identified in our study involved the participants’ use of professional support networks and seeking professional development opportunities to address areas of professional incompetence. Accordingly, this theme aligns with aspects in the MSJCCs’ self-awareness domain. As articulated in this domain, multiculturally competent counselors are expected to have an awareness of their social group statuses, power, privilege, and oppression, as well as acknowledge how their biases, attitudes, strengths, and limitations may influence clients’ well-being (Ratts et al., 2015). The counselors in our study engaged in both informal and formal action-oriented strategies, such as consultations and ongoing supervision with other mental health professionals, that helped them examine prejudicial beliefs, prevent the development of additional biases, and explore other areas of vulnerability and skills deficiencies as designated in the MSJCCs’ counselor self-awareness domain. This finding supports past research (Bowen & Caron, 2016; Reed & Smith, 2014) that indicated that because of the limited resources and remoteness in rural, impoverished areas, professional support is vital to assuage frustrations because of consistently seeing poor, rural clients navigate difficult life circumstances. However, this finding expands current understanding by focusing on the counselors’ ability to identify their own limitations and readily seek out additional supports.
Implications for Counseling Practice, Advocacy, and Training
Foremost, in order to offer culturally competent mental health counseling, it is important for counselors to appreciate their clients’ worldviews and life experiences and understand the unique oppressions that clients from rural, impoverished communities experience. For example, participants acknowledged that various contextual factors, such as family structure, mental illness stigma, and nuances in the natural support systems, shaped their clients’ worldviews and influenced their utilization of mental health treatment. Viewing clients’ concerns from a socioecological lens may strengthen the counselor–client relationship (Ratts et al., 2016) and decrease stigma related to mental health treatment (Stewart et al., 2015).
Counselors also must be flexible and recognize that altering the format of session delivery is often necessary to engage with clients in rural poverty. Individuals living in rural poverty face immense financial barriers that impede the utilization of mental health treatment (e.g., transportation issues), and there is a general lack of awareness about mental illness in rural, poor communities (Haynes et al., 2017). Thus, counseling in rural poverty should extend beyond office-bound interventions to include community-based interventions (Ratts & Greenleaf, 2018) and account for barriers that influence treatment utilization. For instance, the findings indicated that participants had a greater appreciation for clients’ worldviews and expanded their roles to include consulting, advocacy, and case management when they became more engaged in their clients’ personal environment and community.
Furthermore, counselors in this study collaborated with and on behalf of clients in advocacy efforts in various areas such as housing, criminal justice, social services, and school systems. Engaging in individual- and systems-level advocacy interventions (Ratts et al., 2016) when working in rural, impoverished communities is vital to promote equity and positive systemic changes (Reed & Smith, 2014). Given these findings, counselors should become comfortable with professionals in these areas as well as going into the respective environments. Thus, it warrants counselors to network with community partners, schools, faith communities, and law enforcement entities to establish relationships to enhance support networks. In addition, writing letters to federal and state legislators regarding national issues such as Medicaid funding is critical to address policies that benefit rural, impoverished communities.
Finally, multicultural and social justice competence is a developmental process, and professional counselors as well as counselors-in-training need opportunities for ongoing self-reflection to examine their personal assumptions and biases and enhance their skills when working with rural, impoverished communities. Clinical supervision grounded in a social justice framework can help counselors and supervisors process their biases and assumptions, develop a social justice lens of understanding clients from rural poverty, and cultivate advocacy skills (Smith et al., 2013). The MSJCCs should be facilitated throughout counseling program curricula versus one foundation course in multicultural counseling and development. Some possibilities for incorporating the MSJCCs into student learning across all courses include experiential activities, group work, and role-plays that cover topics such as worldviews, intersecting identities, power, privilege, and social class. For example, audiovisual materials found on the Rural Health Information Hub website (www.ruralhealthinfo.org) can help students visualize the experiences of rural and impoverished communities. Additionally, encouraging or requiring counselors-in-training to engage in rural, economically disadvantaged communities for their practicum and internship experiences can be incorporated into the clinical sequence in counselor preparation programs
Recommendations for Future Research
There are several pathways to advance research pertaining to mental health counseling and social justice advocacy in rural poverty. Rural, impoverished areas continue to experience low mental health literacy, which perpetuates stigma. Thus, investigations about stigma in rural poverty can provide insights into the underutilization of mental health treatment in rural communities. Research of various designs regarding the lived experiences of poor women, men, and children in rural communities can inform culturally responsive counseling practices. For example, empirical studies about the experiences of grandparents raising grandchildren in rural poverty can offer unique perspectives for ways to enhance mental health literacy and increase utilization of mental health services. Additional studies are also needed to explore social justice advocacy interventions that are necessary to test the efficacy of the MSJCCs.
Finally, a primary limitation of this study was that the participants had varied professional license levels, areas of specialization, years of professional experience, and provided counseling services to diverse clientele in various settings. The data in the current study did not allow us to assess if variances in the noted areas had a differential impact on the participants’ counseling experiences in rural poverty. Consequently, additional qualitative studies that allow researchers to examine these differences more pointedly are needed to fully understand the experiences of counselors from varied backgrounds and experience levels. Furthermore, readers should exercise caution when generalizing the experiences of the 15 participants in this sample to other counselors working in rural, impoverished communities. The experiences of participants in this sample may not capture the experiences of all counselors working in these communities; however, readers can make decisions regarding the degree to which the findings of the study are applicable to the settings in which they live and work (Hays & Singh, 2012).
Poverty significantly impacts the mental health of children and adults living in rural communities, resulting in having limited access to resources and services that can promote healthy development and well-being. Therefore, mental health counselors working in rural, poor communities must often incorporate social justice advocacy within the context of clients’ experiences of oppression in their counseling practices to provide culturally responsive services. The MSJCCs provided a lens to explore the knowledge, skills, beliefs, and overall practices of 15 professional counselors working in rural, impoverished communities. By examining the experiences of these counselors, we identified how counseling professionals working in rural, impoverished communities acknowledged and appreciated their clients’ worldviews and life experiences, created strong therapeutic alliances, altered counseling service delivery, engaged in advocacy, and sought professional support to sustain their ability to provide culturally responsive counseling services. Multiculturally competent counselors should continually explore ways to amend their current practices to address the various sociocultural barriers that impede the mental health and well-being of rural, poor children and adults. It is our hope that counselors will utilize the findings from this study to further the discourse on rural poverty and create positive change in these communities.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Loni Crumb is an assistant professor at East Carolina University. Natoya Haskins is an associate professor at the College of William and Mary. Shanita Brown is an instructor at East Carolina University. Correspondence can be addressed to Loni Crumb, 213B Ragsdale Hall, Mail Stop: 121, Greenville, NC 27858, crumbL15@ecu.edu.
Saundra M. Tomlinson-Clarke, Colleen M. Georges
The 2013 publication of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) marked the reemergence of issues related to the appropriateness of diagnosis and the uses of the DSM-5 within the counseling profession. Concerns focus on the implications of the DSM-5 for counseling professionals whose professional identity is grounded in a prevention and wellness model, and the impact of the diagnostic process on counseling ethical practice. In this article, the authors explore the use of the DSM-5 in counseling training and practice. The authors also discuss integrating DSM-5 diagnosis into a counselor training framework while maintaining a wellness orientation. Multicultural and strength-based considerations are recommended when using the DSM-5 in counseling training and practice, while maintaining consistency with a philosophical orientation focused on development and wellness and delivering services that are indicative of a unified counseling professional identity.
Keywords: diagnosis, DSM-5, strengths, wellness, counselor training, multicultural
The history of the counseling profession dates back to the vocational guidance movement of the early 1900s. As society became increasingly industrialized, a need arose to improve individuals’ vocational choices (Whiteley, 1984). With a focus on helping people to resolve problems in living, the counseling profession has maintained an emphasis on growth, prevention and early intervention across the life span (Gladding, 2013). Counseling is defined as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan, Tarvydas, & Gladding, 2013). According to Remley and Herlihy (2014), many problems and issues that people face are developmental in nature. A wellness orientation toward helping and help seeking and the use of holistic approaches to treatment distinguish professional counselors from other mental health professionals (Mellin, Hunt, & Nichols, 2011). A focus on normal development and positive lifestyles promotes counselor professional identity and unifies the counseling profession (Gale & Austin, 2003). Given its common historical roots of assisting individuals with educational, occupational and emotional well-being (Whiteley, 1984), the field of counseling psychology also “maintains a focus on facilitating personal and interpersonal functioning across the life span. . . [with] particular attention to emotional, social, vocational, educational, health-related, developmental, and organizational concerns” (Society of Counseling Psychology, American Psychological Association, Division 17, 2014). Therefore, counselors, counseling psychologists and counselor educators benefit from understanding the dynamics of human growth and development in developing responsive interventions for clients with mental health concerns (Ibrahim, 1991). Furthermore, in creating a shared vision for supporting counselors, services to clients and the counseling profession, “advocat[ing] for optimal human development by promoting prevention and wellness” was among the six critical themes identified at the Counselor Advocacy Leadership Conference (Kaplan & Gladding, 2011, p. 368).
With the publication of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2013), issues related to counselor professional identity, diagnosis and the use of the DSM-5 within the counseling profession have reemerged. Concerns focus on the implications of the DSM-5 for counseling professionals who advocate prevention and wellness, and the impact of the diagnostic process on counseling ethical practice (Kress, Hoffman, Adamson, & Eriksen, 2013). Also, multicultural and contextual considerations may be ignored when adhering to a medical model implied by the DSM system. Despite these criticisms, few models exist for integrating diagnosis using the DSM-5 into a wellness and prevention orientation, which is central to professional counseling training and practice. Our goal is to explore the use of the DSM-5 in counseling training and practice, and to suggest ways that DSM-5 diagnosis might be integrated into a counselor training framework while maintaining a wellness orientation.
DSM and Counseling Training
Distinguishing counseling from other mental health professions by a focus on human development, prevention and wellness does not exclude counseling professionals and trainees from acquiring an understanding of behavior across the adaptive-maladaptive continuum. In promoting a counselor professional identity, and reinforcing the consensus definition of professional counseling as empowering individuals, families and groups, teaching diagnosis using the DSM-5 to counseling trainees requires a cultural and contextual understanding of individuals and their concerns. Providing counseling trainees with learning experiences designed to foster knowledge and skills extends beyond exposure to the DSM-5 classification systems for categorizing behavior identified as disordered. Successfully integrating knowledge, skills and practices of diagnosis and the DSM-5 into counselor education involves a review of counselor common core curricular and professional practice (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2009).
In the requirements for common core curricular experiences and demonstrated knowledge, CACREP (2009) requires that all counseling trainees learn about “the nature and needs of persons at all developmental levels and in multicultural contexts” (II.G.3, p. 10), including “theories for facilitating optimal development and wellness over the life span” (II.G.3.h, p. 10) and about “human behavior, including an understanding of developmental crises, disability, psychopathology, and situational and environmental factors that affect both normal and abnormal behavior” (II.G.3.f, p. 10). Furthermore, the standards for Addiction Counseling and Clinical Mental Health Counseling specifically require demonstrated “professional knowledge, skills, and practices” (CACREP, 2009, III, p. 17; p. 29), use of the current DSM and use of other diagnostic tools. Therefore, in addition to common core curricular experiences that develop knowledge and skills needed for “facilitating optimal development and wellness over the life span” (CACREP, 2009, II.G.3.h, p. 10), professional counselors must have diagnostic knowledge, skills and practices. This includes understanding “etiology, the diagnostic process and nomenclature, treatment, referral, and prevention of mental and emotional disorders” (CACREP, 2009, III.C.2, p. 30) and “the range of mental health service delivery” (III.C.5, p. 30). Specifically, CACREP (2009) standards require that counseling trainees must evidence knowledge, relevant skills and practices that include the following: knowledge of the use of the current edition of the DSM (i.e., DSM-5), an understanding of possible biases that might occur when using diagnostic tools with culturally diverse clients, knowledge of the correct use of diagnosis during a traumatic event, and the ability to differentiate “between diagnosis and developmentally appropriate reactions” to traumatic events (CACREP, 2009, III.L.3, p. 34). Moreover, in demonstrating knowledge, skills and practices of the diagnostic process, counseling trainees must understand the implications of diagnosis and treatment interventions. To this end, Kress et al. (2013) stressed the importance of weighing both the benefits and risks of diagnosis when working with clients.
DSM-5 and Counseling Practice
Despite goals of revising the diagnostic classification scheme to make it “more clinically valuable and more biologically valid” (Nemeroff et al., 2013, p. 2), and of acknowledging cultural variations in clients’ expressions of their concerns (Brown & Lewis-Fernández, 2011), the DSM-5 has been criticized from within and beyond the psychiatric community. Released in May 2013, the DSM-5 was met with controversy from mental health professionals and organizations representing their interest in providing effective clinical mental health services to clients (Washburn, 2013). Many viewed the DSM-5 as an extension of the traditional medical model of diagnosis. For example, Ladd (2013) criticized DSM diagnosis for (1) ignoring the therapeutic alliance as a critical aspect of treatment; (2) depending on “statistically acquired symptoms” and “specific rules and timelines” created by Task Force/Work Group professional experts (p. 2); and (3) gearing its usefulness toward “insurance companies, managed care agencies and other professionals in the health care system” (p. 3). The American Mental Health Counselors Association (AMHCA) DSM-5 Task Force (2012), among other groups, submitted feedback to improve the DSM-5 draft. Although the DSM provides a common language for presenting client problems (Hinkle, 1999), the language and assumptions associated with the criteria for diagnosis became the focus of criticism. Stressing the important distinction of “separating the art of mental health diagnosis and complying with the mental health diagnosis business,” Ladd (2013, p. 3) described the DSM as “the diagnostic instrument for the ‘mental health diagnosis business’ with categories and labels used as the language for insurance reimbursement, pharmaceutical treatment, and collaboration between experts” (p. 3).
Due to a growing need for quality mental health services, counseling professionals are providing services to clients presenting with a diverse range of concerns. Counselors are often required to diagnose clients’ problems using the DSM-5 (Miller & Prosek, 2013). DSM diagnosis is necessary for counselors to access managed care and insurance company reimbursements (Hinkle, 1999). However, a traditional use of the DSM may pathologize behavior and separate diagnosis from treatment interventions (Ivey & Ivey, 1999). Counselors faced with these ethical dilemmas may question their professional identity, the usefulness of a wellness orientation and the effectiveness of counseling-related tasks (McAuliffe & Eriksen, 1999; Mellin et al., 2011). Counselors’ challenge to adhere to a wellness orientation as the foundation of their professional identity may be further tested by other mental health professionals’ tendency to conceptualize health and illness using models of pathology and remediation (McAuliffe & Eriksen, 1999). These dilemmas in counseling practice are more likely to become problematic when counselors are not grounded in a strong professional identity. Gale and Austin (2003) encouraged counselors to embrace a wellness model rather than an illness or deficit model of help seeking and treatment planning. Counselor clinical judgment is critical to the diagnostic process. Notwithstanding criticisms of the DSM, Johnson (2013) asserted that diagnosis is directly related to the philosophical and theoretical orientations of the clinician. The medical model used in diagnosis negatively impacts clients’ willingness to seek help for their concerns, and also influences mental health professionals’ orientations toward deficit models (McAuliffe & Eriksen, 1999).
Important considerations for teaching the DSM are directly related to understanding the diagnostic process and implications for models of helping used to conceptualize counseling goals and interventions with clients. Given the focus on prevention, wellness and health across the life span, key questions arise when teaching the DSM-5 to counseling trainees from a traditional medical model that is “focused disproportionately on the physical aspects of illness” (Ingersoll, 2002, p. 115). A traditional disease model views the helper as the expert responsible for healing the client (McAuliffe & Eriksen, 1999). Brickman et al. (1982) viewed this model of helping as deficient in that the helper fosters dependency, which is antithetical to an empowering therapeutic relationship. Teaching the DSM-5 to counseling students requires an understanding of a developmental and wellness orientation. Models of helping must be philosophically and theoretically congruent with a professional counseling identity. To this end, counseling trainees must be challenged to examine their beliefs about seeking help and their view of a helper in the counseling relationship. Diagnosis and treatment should not be separate; rather, diagnosis should occur in conjunction with treatment (Ivey & Ivey, 1999). Viewing clients from a holistic perspective assumes that the greatest source of information lies within the client, not a manual or system of classifying disorders. Focusing on clients’ strengths rather than deficiencies helps to empower clients as part of their learning and development. Integrating multicultural and strength-based considerations as part of the diagnostic process helps to ensure that clients receive culturally responsive counseling interventions.
Integrating Multicultural and Strength-Based Considerations
Counselors, counseling psychologists and counselor educators have been instrumental in recognizing the role of culture and integrating multicultural perspectives in an attempt to understand behavior more fully (Pedersen, 1991; Sue, Sue, Sue, & Sue, 2014). Although racial-ethnic minority groups remained underrepresented in research examining psychopathology, African-American and Hispanic or Latino clients are more likely to be diagnosed, to receive diagnoses of greater severity and to experience less effective treatment outcomes than are White clients (Johnson, 2013; Sue & Sue, 2013). Consequently, multicultural counselor competencies are necessary to address counselors’ culturally biased assumptions and to increase counseling effectiveness in a society changing in culture and diversity (Arredondo et al., 1996; Pedersen, 1987, 2003; Sue, Arredondo, & McDavis, 1992; Sue et al., 1982; Sue & Sue, 2013). Multiculturalism integrates culturally specific and universal perspectives in explaining the dynamics of behavior and developing culturally responsive approaches to treatment. However, counselors may ignore multicultural considerations when adhering to a medical model implied by the DSM. Ivey and Ivey (1999) called on counseling professionals to apply multicultural perspectives when using the DSM. In advancing a contextual understanding of behavior and disorders, Sue et al. (2014) developed a multipath model using four dimensions (i.e., biological, psychological, social and sociocultural) to describe etiological explanations of abnormal behavior.
Social, cultural and economic considerations must be acknowledged when attempting to identify and classify behavior diagnosed as maladaptive. Sue et al. (2014) distinguished cultural universality from cultural relativity in describing behavior within a sociocultural context. Important cultural nuances may be misunderstood when viewed by others who are culturally dissimilar. The result is the labeling of culturally normal behavior as maladaptive. To this end, myths associated with abnormal behavior have led to the social construction of diagnostic categories, which have been cited as major criticisms of using the DSM. Among these faulty assumptions is the belief that abnormal behavior can be readily recognized, distinguished from normal behavior and therefore categorized according to a diagnostic classification scheme (Maddux, 2002; Sue et al., 2014). Maddux (2002) further stated that diagnostic categories used in making biased clinical judgments lead to culturally unresponsive treatment interventions. Inherent in this approach is the basis of the medical model, in which clients are more often treated for pathological behavior (McAuliffe & Eriksen, 1999).
A step toward more holistic diagnostic practices appeared in the DSM-5 in the form of dimensional rather than categorical assessments. These dimensional assessments of every categorical diagnosis were designed to assist counselors with diagnosis and treatment planning (Jones, 2012). Unlike previous versions of the DSM that used a categorical system, dimensional assessments view disorders on a continuum, representing varying degrees of a behavior (Sue et al., 2014). The dimensional assessment also allows counselors to consider individual differences and the influences of race and culture (Johnson, 2013). With the dimensional model, counselors are able to determine whether a diagnostic criterion is present and rate its severity (Brown & Lewis-Fernández, 2011). Viewing disorders on a continuum of behavior may decrease comorbidity; however, it also may affect clients’ accessibility to services by eliminating clients who might have formerly met the criteria for diagnosis or diagnosing clients with a disorder that would have been excluded based on the former criteria. Examples include autism spectrum disorder and depression resulting from bereavement, respectively. Given these changes, the effect of the DSM-5 on diagnosis may impact clients’ access to mental health services and create ethical dilemmas for counselors related to over- and undertreatment.
In addition to the dimensional assessments, the DSM-5 also contains disorders associated with cultural issues. Psychosocial factors are included by using V codes from the World Health Organization’s (WHO) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM; WHO, 1979) and Z codes from the International Classification of Diseases, Tenth Revision (ICD-10; WHO,1992), as well as three new terms: cultural syndrome, cultural idiom of distress and cultural explanation or perceived cause (Pomeroy & Anderson, 2013). Counselors must become familiar with the ICD-10-CM diagnostic codes, which will become the standard medical coding system in the United States beginning October 1, 2015. Inclusion of psychosocial factors evidences the relationship between psychosocial factors and mental health. Multicultural considerations in diagnosis allow mental health practitioners to understand cultural and individual characteristics that define identity and experience. These characteristics of a client’s identity are multiple and interlocking. The uniqueness that defines a client may be lost if group generalizations as represented by the DSM-5 are used as the only means of understanding a client’s experiences. Critical to understanding clients and their stories is the ability to conceptualize clients as individuals interacting within the sociocultural context in which they live. This also involves hearing clients’ stories from their perspective, using their own words.
The importance of cultural influences on mental health diagnosis also is demonstrated by the inclusion of the Cultural Formulation Interview (CFI; Pomeroy & Anderson, 2013). The CFI was developed to improve cross-cultural diagnostic assessment and was created from the Outline for Cultural Formulation (OCF) of the DSM-IV (Aggarwal, Nicasio, DeSilva, Boiler, & Lewis-Fernández, 2013). In keeping with multicultural competency models, the CFI provides a way for counselors to explore and understand clients’ experiences and worldviews, as well as clients’ cultural explanations and interpretations of their concerns. However, Aggarwal et al. (2013) cautioned that the overstandardization of the CFI may result in counselor and client barriers such as the following: a counselor misunderstanding the problem and the problem severity, a lack of conceptual relevance between the client’s concern and counseling interventions, and a counselor and client’s lack of acceptance and unwillingness to engage in the process. Counselors’ ability to develop authentic and caring relationships is essential to accurate diagnosis and relevant counseling interventions. When clients are viewed as unique and counselors understand their experiences, accurate diagnosis and ethical practice are ensured (Swartz-Kulstad & Martin, 1999).
Moving beyond an illness model toward a counselor-client collaborative wellness model begins with a process of engaging with the client, gathering the information needed for assessing the client and trusting in the therapeutic alliance to accomplish the goals of treatment (Ivey & Ivey, 1999). Contrary to the medical or illness model, in which the client’s weaknesses or deficiencies precipitate the diagnosis, treatment and policy decisions, the integration of a strength-based framework and counselor preparation ensures a holistic approach to assessment and treatment (Wright & Lopez, 2002). Working with clients from a holistic perspective requires knowledge and skills that preserve the integrity of the counseling profession by embracing multicultural and strength-based considerations. A framework adapted from positive psychology, defined as “the study of . . . what is ‘right’ about people––their positive attributes, psychological assets, and strengths” (Kobau et al., 2011, p. e1), assists in bolstering resilience and promoting mental health.
Strength-Based Approaches to Diagnosis
Character Strengths and Virtues
Character Strengths and Virtues: A Handbook and Classification (CSV; Peterson & Seligman, 2004), which its authors dub a “Manual of the Sanities” (p. 3) in the introductory chapter, was developed in part as a companion to the DSM that focuses on classifying what is right about people. It includes explicit criteria for character strengths and launched the development of several assessment tools that aid in diagnosing one’s strengths in the way that the DSM diagnoses one’s limitations. Character strengths are the foundation of strength-based approaches and provide a way to assess client functioning from a wellness orientation (O’Hanlon & Bertolino, 2012). The CSV distinguishes three conceptual levels: (1) virtues: core characteristics that moral and religious philosophers esteem; (2) character strengths: processes that define virtues; and (3) situational themes: practices that lead people to establish specific character strengths in certain situations.
Parallel to the DSM, the CSV outlines 10 specific criteria that must be satisfied to warrant inclusion as a character strength. Using these criteria, 24 character strengths were identified under the respective umbrellas of six core virtues: (1) wisdom and knowledge (creativity, curiosity, open-mindedness, love of learning, and perspective); (2) courage (bravery, persistence, integrity, and vitality); (3) humanity (love, kindness, and social intelligence); (4) justice (citizenship, fairness, and leadership); (5) temperance (forgiveness and mercy, humility and modesty, prudence, and self-regulation); and (6) transcendence (appreciation of beauty and excellence, gratitude, hope, humor, and spirituality). The CSV also broadly outlines strength assessment strategies, as well as interventions that further cultivate strengths. For example, counselors might assist clients in realizing or reaffirming their virtue of strength of courage by exploring the will to achieve goals while facing external or internal opposition (O’Hanlon & Bertolino, 2012). This exercise empowers clients and provides counselors with a positive rather than a negative assessment of client behavior. Similarly, the use of positive talk moves clients away from a perspective of deficiency and illness toward encouragement and motivation for change.
Using the CSV in conjunction with the DSM enables counselors to help their clients identify, take pride in and use their character strengths and virtues to enhance well-being in all areas of their lives. Gander, Proyer, Ruch and Wyss (2013) found that using one’s signature strengths in a different way lowered depression and boosted happiness for six months. Wood, Linley, Matlby, Kashdan and Hurling’s (2011) longitudinal study determined that using one’s strengths was correlated with well-being; decreased stress; and greater self-esteem, positive affect and vitality, with the effects still present at three-month and six-month follow-ups. Furthermore, the majority of positive counseling interventions focus on character strength interventions, which have been found to benefit both adults and children dealing with depression and anxiety (Rashid & Anjum, 2008; Seligman, Rashid, & Parks, 2006).
Client diagnosis and conceptualization using the DSM-5 may be incomplete if clinicians do not consider clients’ environmental resources, well-being and strengths (Snyder et al., 2003). Minor alterations to this diagnostic system could promote emphasis on positive functioning and provide information that could contribute to a more complete client picture and conceptualization. Recommendations for rescaling the Axis V Global Assessment of Functioning (GAF) Scale of the DSM-IV-TR included creating a functioning baseline, with the current GAF level of 100 (absence of symptomatology) rescaled to a midpoint of 50. This would have encouraged practitioners to identify and use client strengths, with a GAF of 1 representing severely impaired functioning, 50 representing good health and 100 representing optimal functioning. Snyder et al. (2003) also suggested adding personal strengths and growth facilitators through three brief questions and four positive psychology assessments that measure hope, optimism, personal growth initiative and subjective well-being. Similarly, Magyar-Moe (2009) suggested using a seven-axis system of positive psychological assessment that included documenting positive and negative aspects of clients’ cultural identities, as well as clients’ personal strengths as facilitators of growth.
These exercises, based in positive well-being, are consistent with a wellness orientation of helping and should not be solely limited to clients’ growth and development. Counseling trainees and professional counselors benefit personally and professionally when functioning from a strength-based orientation. For example, based on findings from attribution theory, negative labels affect motivation for change (O’Hanlon & Bertolino, 2012). Therefore, O’Hanlon and Bertolino cautioned against using negative diagnostic labels that may communicate a belief that clients are unable to change. From this perspective, counselors must continually examine their own behavior and the subtle messages that clients might receive during counseling. Through strength-based exercises, counselors are encouraged to promote strengths and resilience as part of an ongoing reflective practice.
Teaching the process of diagnosis using the DSM-5 to counseling trainees is not an easy undertaking. Developed as a tool that promotes a language for use in the larger mental health system (Hinkle, 1999), the DSM is required learning for counseling trainees, and demonstrating professional knowledge, skills and practices is required for professional counselors. Teaching the basic vocabulary and criteria associated with disorders is only the first level of discussion. Effectively teaching diagnosis informed by multicultural and strength-based perspectives includes acknowledging the purpose and limitations of the DSM-5, and examining beliefs about helping, and the role and behavior of helpers. Counselors must explore the concept of normal behavior and their ability to identify abnormal behavior, as well as factors influencing growth and change.
Peterson (2013) stated, “we have developed a wonderful vocabulary that explains what goes wrong with folks and we have almost nothing to say about what can go right with folks” (p. 7). Teaching diagnosis and the DSM-5 integrated with multicultural and strength-based considerations helps counselors to understand what goes right with clients. Through this understanding, clients’ strengths, character and virtues become the support for growth and change within the counseling relationship. Rather than focusing on illness and deficiencies, counselors and clients acknowledge strengths and use them to assist clients in resolving problems in life. Informing the diagnostic process with multicultural and strength-based considerations fosters a holistic view of clients and reinforces counselor advocacy of optimal human functioning. Counselors must consider culture, context and strengths for the diagnostic process to be useful in working with clients from a wellness orientation (Adams & Quartiroli, 2010).
Furthermore, multicultural and strength-based practice considerations encourage reflection and counselor reflective practice, which challenge culturally biased assumptions that negatively affect counselor judgments about clients and the diagnostic process. As a result, counseling professionals do not view clients as confined and limited to a diagnosis; rather, they conceptualize clients as resilient and evolving (Adams & Quartiroli, 2010). Recognizing limitations and possibilities of the DSM-5, embracing a wellness and holistic orientation, and understanding clients from their cultural and situational contexts with a focus on strengths are critical factors that reduce ethical dilemmas and support the use of the DSM-5 in counseling training and practice (Adams & Quartiroli, 2010; Gale & Austin, 2003; McAuliffe & Eriksen, 1999). Integrating multicultural and strength-based considerations into counseling training and practice increases the likelihood that counselors will embrace a professional identity congruent with a wellness orientation when using the DSM-5 as a tool in the diagnostic process (Mannarino, Loughran, & Hamilton, 2007).
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Saundra M. Tomlinson-Clarke is an Associate Professor at Rutgers University. Colleen M. Georges is an Adjunct Professor at Rutgers University. Correspondence can be addressed to Saundra Tomlinson-Clarke, 10 Seminary Place, New Brunswick, NJ 08901-1183, email@example.com.