Perceptions of At-Promise Youth in a Therapeutic Youth Mentoring Program

Diane M. Stutey, Abigail E. Solis, Kim Severn, Lori Notestine, Kodi L. Enkler, Joseph Wehrman, Molly Cammell

 

There is a need for mental health interventions for youth in the United States. Youth mentoring programs have proven to be successful in helping in a variety of aspects. The purpose of this phenomenological study was to gain insight into the lived experiences of participants in a therapeutic youth mentoring program. In addition to being paired 1:1 with a mentor, all of the youth had access to individual counseling with counselors-in-training throughout the program. The participants in this study were 14 youth, ages 11–15, who were considered at-promise youth if they were not reaching their full potential in the school setting and might be vulnerable to school dropout, substance use/misuse, and/or criminal behavior. All participants were interviewed at the beginning and end of a 12-week therapeutic mentoring program. Five themes emerged from the data: life stressors, self-awareness, trusting others, adaptability and resiliency, and hope for the future. Researchers observed an increase in participants’ self-esteem, self-efficacy, and problem-solving and coping skills. Implications for counselors, particularly those interested in adding a therapeutic component to traditional mentoring programs, are discussed along with suggestions for future research.

Keywords: mentoring programs, therapeutic, mental health interventions, at-promise youth, phenomenological

Because of a staggering dropout rate of 1.2 million students a year, as well as an increase of juvenile delinquency in the United States, there is a need for interventions that will help youth stay in school and out of the juvenile justice system (Weiler, Chesmore, et al., 2019; Weiss et al., 2019). Researchers have indicated that the absence of education, including students who do not graduate from high school, has led to an increase of youth experiencing health complications, substance abuse, social skill deficits, and premature death (Schoeneberger, 2012; Weiler, Chesmore, et al., 2019; Weiler et al., 2015; Weiss et al., 2019). In the past, youth exhibiting behaviors that might lead to juvenile delinquency were referred to as at risk. However, the term at promise is now utilized by organizations such as the California Education Code (McKenzie, 2019). The phrase at-promise youth describes youth who have the ability to reach their full potential with additional time and resources.

One way to help at-promise youth reach their full potential and feel more engaged at school might be connecting them with a young adult who understands their struggles. Youth benefit from enhanced connectedness to adults outside their immediate family to help them navigate through difficult times, and this relationship can be protective against suicidal behavior (King et al., 2018; Rhodes, 2002). Individuals within adolescent ecosystems have voiced the positive changes youth have experienced by participating in youth mentoring programs (Raposa et al., 2019). At-promise youth might benefit even more from youth mentoring programs that incorporate a therapeutic component to address mental health concerns they may be experiencing (Liang et al., 2013).

Youth Mentoring Programs
      Youth mentoring is a psychosocial intervention in which a nonparental adult and a younger individual aim to develop a supportive relationship (Karcher et al., 2005; Lund et al., 2019; Sacco et al., 2014; Weiler et al., 2013). During the mentoring program, the youth mentees experience a healthy environment, which often leads to them seeking out and learning to cultivate a healthier environment beyond the youth mentoring program. This shift in environment has allowed researchers to observe improvement in self-perception, social acceptance, parent–child interaction, and academic performance of youth participating in mentoring programs (Anastasia et al., 2012). Researchers have found that mentoring programs may also buffer against the impacts of youth exposed to adverse childhood experiences and improve behavioral, social, emotional, and academic outcomes (Centers for Disease Control and Prevention, 2019; David-Ferdon et al., 2016; Durlak et al., 2010; Tolan et al., 2014). The relationship between mentor and mentee is heavily credited to the success of youth mentoring, signifying the importance of the mentee picking a mentor similar to them (e.g., appearance, culture, interests).

Researchers discovered that both mentor and mentee benefit from the dyadic relationship when there is trust and the mentor is consistent, supportive, and encouraging instead of controlling (Marshall et al., 2016; Rhodes, 2002; Weiler, Boat, & Haddock, 2019; Weiler et al., 2015; Weiss et al., 2019). A mentor should be supportive and encouraging, especially when giving advice, which helps the youth to be open to a new perspective (Lund et al., 2019; Rhodes, 2002). Youth who participated in a positive mentoring relationship had increased feelings of connectedness with a trusted adult and higher rates of pursuing purpose (Lund et al., 2019). In addition, by the end of youth mentoring programs, the majority of mentees achieved a sense of self-worth and increased levels of intimacy, communication, and trust because of the dyadic relationship they had established with their mentors (Keller & Pryce, 2012; Rhodes, 2002).

Mentors and Youth Mentees
     Research on youth mentoring programs has described mentees as individuals who are at risk, may have been in the juvenile justice system, or are in danger of offending or reoffending because of a variety of variables (e.g., substance use, academic failure, absences, aggressive behavior, family stressors) present in their lives (Cavell et al., 2009; Haddock et al., 2017; Weiler et al., 2013). Weiler et al. (2013) noted that more than 60% of the youth who participated in a mentoring program in their study had acquired at least a single charge with the juvenile justice system. Numerous researchers have discussed how the role of a mentor in a mentee’s life helped the mentee with improved self-esteem, enhanced health, instilled hope for the future, and reduced reoffending behaviors (Raposa et al., 2019; Rhodes, 2002; Weiler, Boat, & Haddock, 2019; Weiss et al., 2019).

Training is required before being paired with a mentee to ensure the competency of the adult who will be mentoring the youth facing hardships. Anastasia et al. (2012) emphasized the importance of preparatory training and ongoing training so that mentors, who are not in a helping profession, will have the tools necessary to mentor an adolescent successfully. In the preparatory stage of training, mentors learn about maintaining safety, program rules, child-focused social problem–solving skills, and the activities that will be used throughout the program (Anastasia et al., 2012; Cavell et al., 2009).

At the same time, mentors may feel overwhelmed when mentees exhibit mental health issues, behavioral issues, or racial or socioeconomic differences that surpass their basic training and expertise (Marshall et al., 2016; Weiler et al., 2013). With a majority of the adolescents facing difficulties, it can be daunting for the mentor to provide adequate mentoring; therefore, ongoing training is imperative. Ongoing training is meant to help the mentor increase their effectiveness with their mentee (Anastasia et al., 2012), allowing the adult to seek guidance when they start feeling overwhelmed with their mentee’s behavior and actions (Keller & Pryce, 2012). Through ongoing training and interaction with their paired youth, the adult mentor gains a new level of insight and improved health, self-esteem, and self-awareness that they did not have before (Rhodes, 2002).

However, even with ongoing training, mentees may exhibit mental health needs that are beyond the average mentor’s training and skill set. Liang et al. (2013) highlighted that mentees might benefit from receiving traditional therapy to help with their hardships. Therefore, some mentoring programs have added a therapeutic component incorporating trained mental health personnel to positively support both mentors and mentees (Weiler et al., 2013).

Therapeutic Component to Mentoring
     Mental health professionals (e.g., counselors, social workers, psychologists) learn through their education how to be culturally competent, preserve client autonomy, and maintain an unbiased perspective that is crucial when trying to develop a mentoring relationship (Anastasia et al., 2012). Liang and colleagues (2013) emphasized how youth with therapeutic needs benefit from the way therapeutic guidance and a mentoring program complement each other. For instance, if a child is stressed about how to pay for college, then a mentor can help their mentee find resources, while a therapist could focus on teaching healthier coping skills to manage stress (Liang et al., 2013). Working in tandem allows for a two-dimensional approach, a noteworthy difference between therapeutic mentoring and traditional mentoring programs (Sacco et al., 2014).

Some therapeutic mentoring programs select mentors from a helping profession and provide additional training and supervision from trained mental health clinicians to create a more therapeutic setting for mentees (Johnson & Pryce, 2013). Other youth mentoring programs include a therapeutic component by incorporating additional staff consisting of mental health professionals, such as counselors-in-training (CITs), to directly address the mental health needs of mentees and support mentors (Sacco et al., 2014; Stark et al., 2021; Weiler et al., 2013). Therapeutic mentoring programs function as an intervention for youth who are engaging in risky behavior or have experienced trauma and other developmental issues (Johnson & Pryce, 2013; Sacco et al., 2014).

Litam and Hipolito-Delgado (2021) discussed how COVID-19 highlighted that communities of color have limited access to health care and education. Marginalized youth and their families may not seek mental health services at all or may be more prone to accept help from non–mental health professionals such as mentors (Dashiff et al., 2009). Therefore, an ideal youth mentoring program might have trained mentors from a helping profession who are supervised by mental health professionals, such as counselors, who are also available to meet with youth throughout the mentoring sessions. However, many mentoring programs are volunteer-based and this may limit access to mental health professionals. In addition, there is a shortage of mental health professionals prepared to work with youth (Dashiff et al., 2009) and there is a treatment gap for mental disorders in children (Patel et al., 2013).

Often youth have access to counselors in their schools, but researchers have found that school counselors report that they have limited time to address ongoing mental health needs (Carlson & Kees, 2013). Litam and Hipolito-Delgado (2021) encouraged counselors to use creative strategies such as reduced or no-cost services when working with communities of color. Dashiff and colleagues (2009) stressed that “innovative strategies of service delivery are needed” when working with youth who may come from poverty or areas with limited access to mental health services (p. 29). Partnering with a university, with a plethora of CITs needing supervised client hours, is an innovative and low- or no-cost approach.  In this scenario, the mentor takes on a therapeutic role with their mentee, but the CIT is available to address and process ongoing mental health concerns. Incorporating CITs in a youth mentoring program allows both mentor and CIT to work together to create an environment in which youth feel safe, encompassing a secure attachment to the therapeutic program (Sacco et al., 2014).

The CIT’s position facilitates insight and awareness for the youth while offering tools that will help them reach their therapeutic goals (Johnson & Pryce, 2013; Sacco et al., 2014). The role of the mentor is to serve as a role model and advocate while maintaining open communication with the CIT to facilitate necessary therapeutic modifications (Sacco et al., 2014). Some researchers have found that as the mentor models healthy behavior, the youth will eventually begin to display a healthier interpersonal and intrapersonal self (Johnson & Pryce, 2013; Sacco et al., 2014). Overall, mentoring programs appear to be an effective intervention for youth that could also benefit from the incorporation of a therapeutic component.

Despite the amount of research being done to understand the relationship between mentor and mentee from different perspectives, there is less data that examines the participants’ lived experiences of a therapeutic youth mentoring program that includes CITs. The purpose of this study was to examine and gain further insight into participants’ lived experiences with a therapeutic youth mentoring program—specifically, a therapeutic youth mentoring program in which the mentors had additional training and supervision in mental health areas and additional support was provided by CITs while under supervision. The overarching question for this study was: What were participants’ lived experiences prior to and after participating in a therapeutic youth mentoring program?

Methodology

Phenomenology was utilized in this study to gather and analyze data in order to better understand participants’ lived experiences in a therapeutic youth mentoring program. According to Trusty (2011), “if little is known about a research area or target population, it is likely that a qualitative study would be needed first” (p. 262). Although some research has been conducted with participant perceptions of youth mentoring programs, there is less research with therapeutic mentoring programs; therefore, a qualitative approach was deemed appropriate.

Therapeutic Youth Mentoring Program
The therapeutic youth mentoring program in this study was at a university in the Rocky Mountain region of the United States and utilized the theoretical framework of Campus Corps (Weiler et al., 2013, 2014), now called Campus Connections (CC). CC is an innovative licensed program combining practices from mentoring, after-school programming, and integrated mental health. CC mentors were recruited and selected from a variety of undergraduate disciplines across campus, with more than half being from counseling and human services, psychology, or education majors. All mentors attended an orientation and background screening prior to being accepted for the program. The mentors who were selected spent the first 3 weeks of the semester in intensive training with counselor educators, who were also licensed professional counselors, to learn about child abuse reporting, ethics of working with minors, crises and trauma, and basic counseling skills. Potential mentees were referred by local school counselors and attended an intake with their guardians to go over the format of the program. Mentors created profiles about themselves that were utilized during the intake so that mentees could select their mentor based on preferences.

Once mentees were paired with mentors, the faculty and staff looked at the information provided by caregivers and counselors, demographics, and other relevant information to create diverse mentor families. Each mentor family consisted of approximately three mentor/mentee pairs. In this study, there were a total of three mentor families and each family was assigned a mentor coach. The mentor coaches were graduate-level counseling students who provided their mentor family with support throughout the semester. In addition, four graduate-level CITs were selected to provide ongoing counseling to mentees throughout the therapeutic mentoring program. All CITs were in their last semester of graduate studies and met weekly with counselor educators for supervision. Two counselor educators and supervisors, also licensed professional counselors, were also present each evening of CC to support mentees, mentors, and CITs.

All youth participated in the 12-week CC therapeutic youth mentoring program that met on the university campus, once a week for 4 hours. This therapeutic youth mentoring program was designed to bring youth to a college campus to help them become more comfortable and familiar with future college and career goals. Youth followed a schedule that consisted of:

  • working for 60 minutes with their mentor on academic and study skills.
  • going on a 30-minute “walk and talk” to learn about different locations on the university campus each week.
  • participating in a 30-minute family-style meal at the dining hall with their mentor family.
  • choosing two 45-minute prosocial or social justice activities.

The prosocial and social justice activities were directed at helping youth learn skills and concepts such as resiliency, coping, inclusiveness, and empathy. These activities were adapted from a manual created by the founders of CC. Each evening, two 45-minute lessons were facilitated by our graduate assistants and CITs and covered topics around the “Big 8” identities (i.e., gender/sex, race, class/socioeconomic status, sexual orientation, ethnicity, religion, age, and ability). Some examples of the activities included: Backpack, an activity adopted from Peggy Mcintosh’s (2003) The Knapsack, that examines privilege and societal benefits; Build a House, an activity designed to illustrate the differences in resources that people have based on socioeconomic status; and Pink, Blue and Purple, an activity designed to discuss assumptions made about gender.

At any point throughout their time on campus, mentors or mentees could request for the youth to have time to meet with a CIT. CITs also routinely set up check-ins with all mentees and were present throughout the entire process. Often the CITs would help with the after-dinner activities if youth weren’t requesting to meet 1:1. The participants in this study engaged in a total of 720 minutes of counseling with the average youth receiving 50 minutes of individual counseling.

Participants
     This was a purposeful sample of at-promise youth participating in the same CC therapeutic youth mentoring program in the spring of 2019. Of the 18 youth enrolled in CC, 14 youth agreed to participate in the research study. The participants in this study consisted of 14 youth, ages 11–15, with the following demographics: 71% male, 21% female, and 7% transgender/gender-expansive; 57% White, 29% Black/African American, 21% Hispanic/Latino, 14% American Indian/Alaska Native, and 7% Asian; and approximately half on free and reduced lunch. School district partners were asked to consider and recommend at-promise youth if they were not reaching their full potential and might be vulnerable to school dropout, substance use/misuse, and/or criminal behavior. Local school counselors submitted referrals based on this criterion for youth to participate in CC. Participation was voluntary and participants could remove themselves from the study at any time throughout the process.

Procedures
     At-promise youth are considered a vulnerable population and therefore researchers must contemplate ethical considerations. Our research team went through a full IRB process to ensure youth participants were being treated with the highest ethical considerations. After obtaining IRB approval, informed consent and assent was secured and two audiotaped interviews were conducted with all participants—one at the beginning of the 12-week mentoring program and one 12 weeks later at the end. Semistructured interviews are progressive in design (Merriam, 1998); they allow the researcher to formulate questions ahead of time and adjust the questions based on the participants’ responses (Guba & Lincoln, 1989). Participants were asked a series of open-ended questions that were similar across interviews, such as how a mentor has helped them, their feelings about being on a college campus, and thoughts on meeting with a CIT (see Appendix for a complete list of interview questions). The final interview allowed the participants to describe their experience working with a mentor and CIT and their perceptions of meeting on a university campus each week for 12 weeks.

Our research team consisted of three PhD-level counselor educators, Diane Stutey, Lori Notestine, and Joseph Wehrman; one counselor education doctoral student, Kim Severn; one staff member in master’s-level student affairs and higher education, Molly Cammell; and two graduate students in counseling, Abigail E. Solis and Kodi L. Enkler. All members of the research team were present throughout the 12-week therapeutic youth mentoring program. We met on a regular basis to discuss the research protocol and any potential conflicts of interest or ethical concerns, ensuring trustworthiness of the study.

Data Analysis and Trustworthiness
     All data were collected by the research team and Solis transcribed all the interviews. Data were analyzed and independently coded by Stutey, Solis, and Severn, utilizing Merriam’s (1998) two-level approach. After each researcher independently coded all the transcripts, we met to discuss and agree upon emerging themes. After data was further analyzed and organized to support each of the themes, we met again to come to consensus on the themes. Any disagreement of themes or supporting data was discussed until consensus was reached.

Several techniques were used to ensure the trustworthiness and rigor of data collection and analysis (Guba & Lincoln, 1989; Merriam, 1998). Stutey, Solis, and Severn independently coded the data and each kept their own researcher journal. To establish dependability and conformability, an audit trail was created (Lincoln & Guba, 1985). Notestine and Enkler served as peer reviewers and assisted Stutey, Solis, and Severn by providing feedback at various points. Peer reviewers were given access to initial emerging themes, final themes, researchers’ journals, and coding documentation to inform the feedback provided to Stutey, Solis, and Severn throughout the data collection and analysis process.

We also used bridling to establish trustworthiness and acknowledge the researchers’ prior and current experiences. Often qualitative researchers will use bracketing in an attempt to manage their understanding of or experience with a phenomenon. However, bridling encourages ongoing researcher reflexivity and is meant to be more intentional, with researchers maintaining openness and revisiting assumptions throughout the research process (Dahlberg, 2006; Vagle, 2009). Stutey et al. (2020) described bridling as “an ongoing reflective practice that takes place before, during, and after data collection” (p. 124). Bridling was chosen over bracketing because the researchers had personal and professional experiences with at-promise youth, making it unlikely to put aside all biases and assumptions. Development of a researcher’s stance and review of researchers’ journals were utilized throughout the data collection and analysis to bridle and manage researchers’ biases and assumptions.

Findings 

In total, five themes emerged from the participant interview data: life stressors, self-awareness, trusting others, adaptability and resiliency, and hope for the future. In order to be considered a theme, at least seven out of the 14 participants had to endorse the theme. Within each theme, there were two to three aspects that were discussed by participants. Each of the themes is discussed in this section, and a sample of participant quotes is provided as evidence of each aspect of the theme. Participants all chose pseudonyms that were used throughout the research study.

Figure 1

Summary of Themes

Themes        Aspects of Themes
Life Stressors ·         School

·         Peers/Bullying

·         Mental Health

Self-Awareness ·         Positive Self-Image

·         Accomplishments

Trusting Others ·         Qualities of a Trusted Mentor/Adult

·         Feeling Understood or Heard

Adaptability and Resiliency ·         Social-Emotional Growth

·         Coping Skills

Hope for the Future ·         Realistic Goals for School

·         Future Careers

·         Impact on Others

 

Life Stressors
     The first theme of life stressors was endorsed by all 14 participants. This theme was defined as participants’ lived experiences of how stressors in their lives were negatively impacting them. Many of the participants shared in the first interview that they were overwhelmed and a bit confused about being on a college campus. Participants were not sure why they were selected for the therapeutic mentoring program or what they might need help with beyond academics. Participants endorsed three aspects of life stressors in the areas of school, peers/bullying, and mental health.

School
     In the initial interview, participants discussed wanting to get straight As and that math was a particularly tough subject area for them. Ball stated, “I really struggle with math. I don’t know why it’s always been something that’s really hard for me.” JT shared that they “have to get straight As” and indicated that if they did not, they would “get kicked out.” Tristonion said, “Right now, I really don’t have the motivation to try in school.”

Other participants struggled with certain teachers, behavior at school, or homework. Josh Billups shared, “Sometimes I’m afraid to talk to my teachers . . . talking to adults is kind of hard.” Drift King stated that they had problems in several areas, such as “not studying, not getting most of the work done, not understanding the work, too afraid to ask teachers, raise my hand, or [ask] questions.” Many participants said that they “don’t like homework” and that they also struggle in school because they “talk too much,” are “not turning in assignments,” and find it “really hard . . . to focus.” School and academic success were important to the majority of the participants in this study.

Peers/Bullying
     Besides academic stressors at schools, participants shared that they sometimes struggled with bullies and many shared having a lack of peer or other support in school. Bam shared that they struggle at school because of “getting bullied and having nobody to talk to . . . somebody told me to go commit suicide.” Isabel stated that there is a lot of “drama . . . and getting bullied” at their school. Isaiah shared feelings of isolation: “Kids were being mean and stuff so I just went and sat [alone].” Others shared that they have been called “a snitch,” “Bible head,” and “God” by students in their schools that they perceive as bullies. Participants felt they could discuss these matters with their mentors and/or CIT and seek their advice.

Mental Health
     Participants also discussed areas of stress that impact them at school such as learning difficulties and specific physical and mental health issues. DTS shared, “I have ADHD . . . and it’s hard getting back on the schedule taking pills every day.” Several participants mentioned struggling with symptoms associated with depression. Isabel stated, “I’ve had a lot of surgeries and I have really bad anxiety and depression.” Isaiah discussed that “everyone is mean to me” and shared that they “don’t have a good memory.” Many participants mentioned that they were using the mental health services of their school counselor and/or the CIT provided through CC but sometimes felt just as comfortable talking to their mentor.

Self-Awareness
     The second theme that emerged from this study was self-awareness. This theme was endorsed by 13 of the 14 participants and is defined as participants’ lived experiences of becoming more self-aware after participating in the 12-week therapeutic mentoring program. When asked about how others perceived them, participants tended to initially interpret that teachers and caregivers might have negative views; often these views were opposite of those that they held about themselves or they perceived peers had about them. After participating in the therapeutic mentoring program, youth seemed more open to talking about their strengths and shared more positive comments about themselves and their accomplishments. Participants endorsed two aspects of self-awareness: positive self-image and awareness of accomplishments.

Positive Self-Image
     Many of the participants shared a negative self-image in the initial interview. After spending time in the therapeutic mentoring program, they viewed themselves, and perceived that others also viewed them, in a more positive light. Andrew shared, “I learned you don’t have to be bad to get where you need to be. You don’t have to be dangerous for people to like you.” Jeffy stated, “I’ve been focusing on my schoolwork instead of messing around all the time. And [I’m] thinking before I do something . . . less getting in trouble.” Josh discussed how their image had changed since participating: “Back then I was kind of mean, but [the program] kind of helped me change that . . . I have a lot more friends now.” Several participants shared that they were getting along better with others and being “more social now,” were “able to talk and interact with other people,” and were “opening up to more people.” Several participants attributed this shift in their self-image to having a mentor and/or CIT who unconditionally accepted them.

Accomplishments
     Along with viewing themselves in more positive ways, many participants shared what they had accomplished during this semester. Andrew stated, “I used to fight a lot and now we [mentor and me] have a goal not to fight. I haven’t fought since.” Drift King shared, “I know that I’ve got to take it [school] seriously. There’s a lot more stuff that I can accomplish in life.” Isaiah discussed that their grades had improved and “I just got accepted to be a web leader.” In fact, many participants shared improvement in their overall well-being, grades, and relationships with peers: “I’ve been more happy,” “Now I have three As and four Bs,” and “I would describe myself as really helpful and caring about other people.” Participants seemed proud to share these accomplishments and were often smiling during the final interview as they discussed ways they had seen improvement.

Trusting Others
     The third theme to emerge was trusting others. This theme was endorsed by 12 of the 14 participants and is defined as participants’ lived experiences with learning to trust others, especially adults. In the initial interview, the participants were unsure of some of their relationships and especially expressed a disconnect with adults. Many participants said that they did not always ask for help or they had some past negative experiences with adults and peers. After participating in the therapeutic youth mentoring program, many participants reported having a trusting relationship with their mentor, and a few with other adults supporting the program, such as mentor coaches and CITs. There also seemed to be some shift in participants having better relationships with peers and other adults outside of the therapeutic youth mentoring program. Participants shared two aspects of trusting others: qualities of a trusted mentor/adult and feeling understood or heard.

Qualities of a Trusted Mentor/Adult
     Many participants shared that they perceived their mentors as someone who will “always be there for you.” Andrew shared, “We had a lot in common. So, I can talk to her and she’ll know the answer.” Ball shared, “I just get someone to talk to other than my parents and friends . . . [he’s] a helpful person that gets you through bad times.” Drift King stated, “They help you with anything I need: anger management, class, social skills, school, someone to talk to like a counselor.” Participants described mentors as “cool,” “funny,” “nice,” “friendly,” “chill,” and “helpful.”

Participants were also asked about their perceptions of meeting with a counselor before and after participating in the therapeutic mentoring program. The majority of the participants shared positive experiences they have had with counselors both at school and during the therapeutic mentoring program, stating they helped “when I’m having a bad day,” “after my Grandpa died,” and “when I was being bullied.” Only one participant, Isabel, mentioned that she trusted the CIT more than her mentor: “She’s super there for me, and I only want to talk to her about my problems, because I don’t feel like I really know any other counselors.” Andrew seemed confused about the roles of the different adults at the therapeutic mentoring program: “I thought they were all like mentor and mentor coaches.” After clarification, he shared that the CITs “bring you up . . . if you are feeling down or unhappy.” Although there may have been some initial confusion about the difference between the CITs and coaches, it seemed that most participants felt comfortable seeking counseling support as needed.

Feeling Understood or Heard
     In addition to sharing qualities that they appreciated about their mentors, participants shared that a mentor is someone who understands them and makes them feel heard. Drift King shared, “I feel like they’ve been through it too, tough times and they succeed . . . I feel they can help you.” Jeffy stated, “We’re really similar, he’s kind of like me. They talk about your weekend . . . and make you feel happier if you had a bad day.” Rene discussed how her mentor “supports me, like if I have a really bad day she helps me out to have a better rest of my day.”

Adaptability and Resiliency
     The fourth theme that emerged was adaptability and resiliency. This theme was endorsed by 10 out of the 14 participants and is defined as participants’ lived experiences of the ways in which they were adapting to some of the stressors that they had shared in the first interview. Participants discussed what they had learned in the therapeutic mentoring program, and often the new resiliency skills seemed connected to experiences with their individual mentor. Participants endorsed two major aspects of this theme: social-emotional growth and coping skills.

Social-Emotional Growth
     Participants shared ways in which they had grown socially and emotionally over the semester. DTS shared, “I made some new friends.” Isaiah stated, “I open up to new people.” Bam discussed how their mentor helped them “get through rough times.” Many participants shared that working with their mentors helped them “deal with stress,” “learn how to socialize,” and “make the right decisions.” Several participants were hesitant to even attend CC initially and by the end, they expressed that they were sad to leave because of the social and emotional connections.

Coping Skills
     Participants also perceived they had better coping skills and strategies for how to approach a variety of problems. Andrew stated, “Yesterday there was a fight, and I didn’t go . . . [my mentor] said, ‘You can always walk away.’” Josh shared that they learned various coping skills such as better “communication skills and knowing people who will help me and be respectful . . . it’s helped me be able to talk and interact with other people.” Tristonion added, “Well, this place teaches us to calm down.” Participants shared that they also “started focusing,” “doing good deeds,” and “hang[ing] with other people.” Several participants shared that the coping skills they were using they had learned either from their mentor or the CITs during 1:1 time or in prosocial activity time.

Hope for the Future
     The fifth and final theme that emerged was hope for the future. This theme was endorsed by 13 of the 14 participants and is defined as participants’ lived experiences surrounding their future hopes and plans. Many participants in the initial interview had lofty goals that did not always seem realistic (e.g., become an NBA or NFL player). Participants also emphasized the importance of having perfect grades and that this is how they would know they were successful. After participating in the therapeutic mentoring program, participants shared what they had learned and their hopes for the future. The three aspects of this theme centered around setting realistic goals for school, the importance of future careers, and the impact they could have on others.

Realistic Goals for School
     At the end of this study, many participants reported improvement in grades but were not stressing about perfection as much. Participants were setting more realistic goals for themselves with school. Drift King shared they were planning ahead for high school and would “take it more seriously than middle school . . . to get the credit to actually graduate.” Super J stated about meeting with his mentor, “It’s probably going to help me be successful at college because they show you how important it is to not give up.” JT discussed how doing well in school would allow them to continue to wrestle and “get first place again.” Many participants seemed to have learned from their mentor and/or CIT more about the college process and what they needed to do now in order to reach future goals.

Future Careers
     Participants were also more interested in what it might take for them to meet their future career goals. Isabel stated, “In September I’m getting my first job . . . and once I graduate high school, I want to be a lawyer in the Air Force.” Josh stated, “I want to get the highest grades I can so I can do activities and get into higher classes to set myself on the right foot for the future.” Josh mentioned the importance of “getting a good education . . . going to college and get[ting] a job.” This youth was considering a variety of occupations such as construction worker or firefighter. Some of the participants even mentioned that after working with their mentor they wanted to “go to college here” and realized that college might help them “be able to have a good job and a good house.” Participants seemed to be making the connection between college and career based on conversations with their mentor and/or CIT.

Impact on Others
     At the same time that participants were discussing their hopes for the future, there were many who also wanted to have an impact on others. Isaiah knew that they wanted to help people and discussed a variety of ways they might do this by being a “teacher, nurse, or school counselor.” Rene was not sure if they wanted to help people or animals, so they were considering “being a veterinarian or a doctor.” Finally, Super J shared, “I kind of want to help other kids—like to be an orthodontist and help kids and fix their teeth.” It is important to note that the majority of the undergraduate mentors are in human services and helping degrees so this may have influenced their mentees on some level.

Discussion

The overarching question for this study was: What were participants’ lived experiences prior to and after participating in a therapeutic youth mentoring program? In this section, the findings are discussed as they relate to answering this overarching question. Furthermore, a discussion of how these findings support and add to the literature on therapeutic mentoring programs is provided.

Consistent with prior research studies on mentoring programs, the participants in this study shared that having a mentor had a positive impact on their overall behavior (DuBois et al., 2011; Tolan et al., 2014; Weiler et al., 2015). Specifically, participants indicated more adaptive and resilient thinking after participating in the youth mentoring program. Lee et al. (2012) indicated that resilience is not fixed but can be learned and fostered through the protective factors in a child or adolescent’s life. Being able to walk away from a fight or potentially violent situation and asking adults for help were two of the outcomes participants described. A few participants even cited the therapeutic youth mentoring program as the reason why they have developed better coping strategies to better handle the stress they feel in their daily lives.

Another finding consistent with the research on mentoring programs was that participants acknowledged the significance of the primary mentoring relationship (Weiler et al., 2015; Weiss et al., 2019). One significant finding between the initial and final interview was the participants’ shared perspective that they trusted their mentor and the other adults supporting the youth mentoring program (e.g., mentor coaches and counselors). Griffith and Larson (2015) stated that when youth have trusting relationships with adults they become “deliberate agents of their own development” (p. 791). Mentors and CITs supporting the youth mentoring program helped to facilitate this development of trust by being present, participating in dialogue, and leading prosocial activities with the youth.

Many participants also described that because of the trust they developed with their mentor, they were able to also trust other adults in their lives, specifically parents, counselors, and teachers. When adolescents have a trusting relationship with at least one adult in their life, help-seeking behavior increases for the youth as well as their immediate peer group (DeLay et al., 2016). Although the majority of the participants shared the positive impact of having a therapeutic component to this youth mentoring program, five of the 14 participants still shared in the final interview that they were hesitant to meet with a counselor (either at school or at the therapeutic mentoring program). Haddock and colleagues (2017) posited that youth who participated in CC might be embarrassed to share about their experiences with counselors. It is important to note that some of the youth participants also did not make the distinction between CITs and mentor coaches. So, more clarity on the role of CITs in youth mentoring programs may be needed.

However, the mentors in the CC therapeutic mentoring program do learn some basic counseling skills and are also trained in crisis intervention. Although development of the relationship with the counselor may be an area of further examination with therapeutic mentoring programs, it seemed that many of the participants felt comfortable discussing mental health issues with their mentors who were being supported by counseling professionals.

Researchers have discovered that when mentees do develop a positive perception of support, this can lead to an increase in academic attitudes and self-esteem, lower frequencies of problem behaviors, and thinking more positively about the future (Chan et al., 2013; Haddock et al., 2017; Raposa et al., 2019; Weiler et al., 2014). In this current study, not only did participants indicate that their grades improved, but they also began to develop a more balanced outlook concerning school and their future college and career goals. Similarly, Weiss and colleagues (2019) discovered that positive academic mentoring relationships help youth find hope for the future and instill a belief that college and career goals can be reached.

In the initial interview, many participants discussed their perceived barriers and stressors to academic and life success, such as learning and mental health challenges. Haft and colleagues (2019) discovered that participation in a peer-mentoring program resulted in reduced depressive symptoms and increased self-esteem in youth with ADHD and learning disabilities. Relatedly, participants in our current study talked more openly about their strengths and hopes in the final interviews, demonstrating more self-awareness, fewer depressive indicators, and a higher sense of self. Perhaps gaining more hope and a higher sense of self led the participants to also focus on ways in which they might positively impact others. This finding is interesting considering that Briggs et al. (2007) posited that some youth might seek out opportunities to volunteer to help others in order to increase their self-worth.

Implications

There are a number of implications of these findings for counselors, particularly those interested in adding a therapeutic component to traditional mentoring programs. First, although many youth mentoring programs have historically focused on the connection between mentor and mentee (Marshall et al., 2016; Rhodes, 2002; Weiss et al., 2019), the results of this study indicate a significant benefit related to the additional attention to the mental health needs of mentees. Throughout the 12-week period, mentees had the opportunity to engage with mental health professionals in a non-threatening context. This added therapeutic component appeared to provide an additional support toward the connections the youth developed with trusted adults.

Another important implication emerging from the results points to the increase in self-esteem and self-efficacy in the context of the variety of relationships and settings available to the youth mentees. A number of youth reported they could envision themselves going to college in the future after having spent time on a college campus and being exposed to a wider variety of career options. Mentoring programs may find value in creating pathways to career and college exposure supported by trusted adults, such as mental health counselors.

An increase in problem-solving and coping skills is an additional finding with significant implications for youth mentoring programs. Most of the youth interviewed shared varied experiences in the program that resulted in developing new ways of adapting to life stressors. This theme emerged in various ways for the youth, indicating that it may be effective for other programs to integrate a variety of experiences, such as psychoeducational and therapeutic components, that focus on adaptive and resiliency skills.

Mentoring programs are important in aiding struggling youth but often fall short because of a lack of resources and consistency and an inability to address the mental health needs of mentees (Weiler et al., 2013). Including counselors and incorporating a therapeutic component in youth mentoring programs may be beneficial to both youth and their mentors. The implications of adding a therapeutic component in youth mentoring programs and psychoeducational activities on a college campus are extensive and indicate that further development and research are imperative.

Limitations and Future Research

There are several limitations within this current study. One limitation is that youth reported initial reluctance to participate in the research portion of the program. For many youth, participating in an individual qualitative interview was a novel experience and establishing rapport was often contingent on the overall volume of engagement. It may be helpful to allow the youth to have their mentors present during the interview because they are a trusted adult.

Further, a few participants expressed confusion regarding the difference in roles between the mentors, CITs, and mentor coaches. Youth and their caregivers do go through a formal intake process, but perhaps further psychoeducation or an orientation for youth on the different roles, in particular of the CITs, would be helpful. In addition, youth only participated in an average of 50 minutes of 1:1 counseling across the 12 weeks. However, there were many times they were interacting with CITs in small groups and large classroom guidance, similar to school counseling. Future studies with therapeutic mentoring programs could provide better clarification on the role of CITs and perhaps provide more structured weekly 1:1 counseling time with all participants.

Additionally, follow-up interviews with youth participants could help determine if identified change behaviors and attitudes continue to persist over time. In particular, it would be interesting to see if youth were more likely to reach out to their school counselor and/or counselors in the community after participating in a therapeutic youth mentoring program. Several participants mentioned they had never met with their school counselor and/or an outside counselor and that meeting with the CIT at CC was their first experience with individual counseling.

Lastly, future research regarding the experiences of mentors, parents, and key stakeholders in participants’ lives (e.g., teachers, parole officers, case workers, school counselors) could provide greater validity and confirmation of universal themes and experiences generated by the therapeutic youth mentoring program. A follow-up quantitative or mixed methods study could confirm and further validate key findings.

Conclusion

Mentoring programs are an effective mental health intervention for at-promise youth, and the addition of a therapeutic component might further enhance this intervention. A qualitative study was conducted to analyze youth’s lived experiences before and after participating in a therapeutic youth mentoring program. The participants in this study consisted of a diverse group of youth who were interviewed at the beginning and end of a 12-week therapeutic mentoring program. In addition to being paired 1:1 with a mentor, all of the youth had access to individual counseling with CITs throughout the program. The five themes that emerged from the data were life stressors, self-awareness, trusting others, adaptability and resiliency, and hope for the future. Some aspects discussed within these themes included peers/bullying, positive self-image, feeling heard or understood, social-emotional skills, and future careers. Researchers observed an increase in self-esteem, self-efficacy, and problem-solving and coping skills in the youth. Finally, youth participating in the therapeutic mentoring program perceived a benefit of having additional attention given to their mental health needs.

 

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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Appendix

Pre Semi-Structured Interview

  1. Tell me what you already know about Campus Connections or having a mentor.
  2. Describe a typical day or week at school.
  3. What do you enjoy?
  4. What is something you struggle with?
  5. What are some ways you think having a mentor could help you (at school, home, in life)?
  6. What are your future goals or plans?
  7. For middle school
  8. High school
  9. After high school
  10. What is something that is preventing you from achieving your goals or future plans?
  11. How could your mentor help you with these challenges?
  12. Tell me about your thoughts/feelings about being on a college campus.
  13. What kind of jobs or careers are you thinking about?
  14. What are your thoughts on meeting with a counselor?
  15. Can you describe a time when a counselor helped you?
  16. How do you think people would describe you?
  17. Teachers?
  18. Parent or guardians?
  19. Peers?
  20. How would you describe yourself?
  21. What is something you wish people knew about you?

Post Semi-Structured Interview

** Remind the student of the pseudonym they chose and ask if they want to keep or change this.

  1. Tell me what you now know about Campus Connections and having a mentor.
  2. How would you describe your mentor?
  3. Tell me a story about your favorite thing about Campus Connections? Least favorite?
  4. Describe a typical day or week at school.
  5. What do you enjoy?
  6. What is something you struggle with?
  7. What are some ways you think having a mentor and participating in Campus Connections helped you?
  8. At school
  9. At home
  10. In life
  11. What are your future goals or plans?
  12. For middle school
  13. High school
  14. After high school
  15. What is something that has been preventing you from achieving your goals or future plans?
  16. Describe how your mentor helped you with these challenges.
  17. Tell me about your thoughts/feelings about being on a college campus.
  18. What kind of jobs or careers are you thinking about?
  19. What are your thoughts on meeting with a counselor?
  20. Can you describe a time when a counselor helped you?
  21. How do you think people would describe you?
  22. Teachers?
  23. Parent or guardians?
  24. Peers?
  25. Mentor?
  26. Counselor?
  27. How would you describe yourself?
  28. Are there things about you that you think have changed/improved since joining Campus Connections?
  29. What is something you wish people knew about you?
  30. What else would you like me or others to know about Campus Connections?

 

Diane M. Stutey, PhD, NCC, LPC, RPT-S, is an assistant professor and department chair at the University of Colorado Colorado Springs. Abigail E. Solis, MA, is a clinical mental health counselor at Colorado Motion. Kim Severn, MA, LPC, is an instructor at the University of Colorado Colorado Springs. Lori Notestine, PhD, LPC, is an instructor and program coordinator at the University of Colorado Colorado Springs. Kodi L. Enkler is a licensed school counselor at Swigert Aerospace Academy. Joseph Wehrman, PhD, LPC, is a professor at the University of Colorado Colorado Springs. Molly Cammell, MA, is Campus Connections program manager at the University of Colorado Colorado Springs. Correspondence may be addressed to Diane M. Stutey, 1420 Austin Bluffs Parkway, Colorado Springs, CO 80918, dstutey@uccs.edu.

Behind the Curtain: Ballet Dancers’ Mental Health

J. Claire Gregory, Claudia G. Interiano-Shiverdecker 

Using Moustakas’s modification of Van Kaam’s systematic procedures for conducting transcendental phenomenological research, we explored ballet culture and identity and their impact on ballet dancers’ mental health. Participants included four current professional ballet dancers and four previous professionals. Four main themes emerged: (a) ballet culture—“it’s not all tutus and tiaras”; (b) professional ballet dancers’ identity—“it is a part of me”; (c) mental health experiences—“you have to compartmentalize”; and (d) counseling and advocacy—“the dance population is unique.” Suggestions for counselors when working with professional ballet dancers and professional athletes, such as fostering awareness about ballet culture and its impact on ballet dancers’ identity and mental health, are provided. We also discuss recommendations to develop future research focusing on mental health treatment for this population. 

Keywords: ballet dancers, culture, identity, phenomenological, mental health

 

“Dancers are the athletes of God.”—Albert Einstein

Professional ballet dancers’ mental health experiences are sparse within research literature (Clark et al., 2014; van Staden et al., 2009) and absent from the counseling literature. Most research including ballet dancers focuses primarily on eating disorders, performance enhancement (Clark et al., 2014), and injuries (Moola & Krahn, 2018). Although these topics are crucial to dancers’ wellness, explorations of ballet dancers’ mental health that do not primarily focus on eating disorders are also important. Increasing professional ballet dancer and athlete mental health research could provide counselors with deeper awareness of the populations’ needs. Further, counselors have access to the American Counseling Association’s (ACA; 2014) Code of Ethics, which is relevant for all clients, including athletic populations. However, the counseling profession lacks specific sports/athletic counseling ethical codes, competencies, and teaching guidelines (Hebard & Lamberson, 2017). The only mention of “athletic counseling guidelines” appears in a 1985 article from the Association for Counselor Education and Supervision (Hebard & Lamberson, 2017). In their initiative to increase counselor response to the need for athletic counseling, Hebard and Lamberson (2017) implored counselors to advocate for athletes’ mental health. Further, the researchers stated that it is common to view athletes as privileged and idolize them for their physical endurance; however, this perception may leave athletes vulnerable to mental health concerns. Recent examples of mental health difficulties experienced by formidable professional athletes include tennis player Naomi Osaka choosing to decline after-match news conferences to safeguard her mental health and gymnast Simone Biles removing herself from some events at the Tokyo 2020 Olympics in order to protect her mental health.

Moreover, scholars have been increasingly devoted to understanding the cultures within which performing artists are trained and developed and recognizing their role in supporting the health and well-being of the artist (Lewton-Brain, 2012; Wulff, 2008). For counselors, the ACA Code of Ethics (2014) promotes gaining knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population (C.2.a). However, this is difficult with limited current data or research seeking to advance knowledge of the culture of performing institutions and how they relate to artists’ mental health experiences. Therefore, an exploration of ballet culture and identity and their impact on ballet dancers’ mental health experiences could help inform counselors and counselor educators about the counseling needs of this population.

Mental Health Among Elite Athletes and Performing Artists
     Because of the scant literature focusing directly on professional ballet dancers’ mental health, we included research findings from articles examining mental health among athletes and performing artists. Although differences exist between professional ballet dancers, elite athletes, and performing artists, a professional ballet dancer straddles multiple environments. For example, an elite athlete trains to win a national title or medal, possesses more than two years of experience, and trains daily to develop talent (Swann et al., 2015). Rouse and Rouse (2004) suggested that performing artists’ goals or outcomes are to create art and achieve a high performance level with audience satisfaction. Similar to these groups, a professional ballet dancer trains almost every day, which requires extreme dedication. They must comply with high physical and mental demands to develop their ballet technique for performing and entertaining audiences.

Scholars have discovered that elite athletes experience a high prevalence of anxiety, eating disorders, and depression compared to the general population (Åkesdotter et al., 2020; Gorczynski et al., 2017). At the same time, eating disorders are overrepresented in elite athlete studies because of the requirement that elite athletes maintain a specific stature for their profession (Åkesdotter et al., 2020). Interestingly, few elite athletes reported anxiety disorders even though they scored in the moderate range on the General Anxiety Disorder-7 (GAD-7; Åkesdotter et al., 2020). This could indicate that elite athletes normalize their anxiety and eating concerns, even at a clinical level. Likewise, performing artists display disproportionately high reporting rates for mental health disorders, such as depression, anxiety, and stress, when compared to the general population (Van den Eynde et al., 2016; van Rens & Heritage, 2021). Given professional ballet dancers’ emotionally demanding performance levels as performing artists and their physicality as athletes, they may share similar mental health experiences with elite athletes and performing artists, yet these experiences remain unknown.

Ballet Culture and Professional Dancers’ Mental Health
     Literature exploring ballet dancers has focused on culture (Wulff, 2008), development (Pickard, 2012),  emotional harm (Moola & Krahn, 2018), injury prevention (Biernacki et al., 2021), and disordered eating (Arcelus et al., 2014). Ballet, with origins in the Italian and French courts, is an age-old culture that fuses beauty and athleticism (Kirstein, 1970; Wulff, 2008). Influenced by social and cultural forces in the Western world (Kirstein, 1970), ballet culture is synonymous with tradition and hierarchy (Wulff, 2008). Ballet culture holds steadfast to idealistic tenets in which dispositions (e.g., tenacity), perceptions of an ideal body, and actions (e.g., constant rehearsals) provide dancers the ability to illustrate a story through movements (Wulff, 2008). Exquisite sets, costumes, and movements create a unique experience and can produce a visceral reaction in the audience (Moola & Krahn, 2018).

Yet a strong commitment to the art form requires ballet dancers to work with their bodies for hours, sustain injuries, and work through chronic pain (Pickard, 2012), often leading to emotional distress (Moola & Krahn, 2018). Physical requirements also make dancers three times more vulnerable, compared to non-dancers, to suffer from eating disorders, particularly anorexia nervosa and those labeled by the Diagnostic and Statistical Manual of Mental Disorders as eating disorders not otherwise specified (Arcelus et al., 2014). van Staden et al. (2009) focused directly on ballet dancers’ mental health, finding that professional ballet dancers also experience mental health concerns due to negative body image and stress. The vast majority of these studies originated from countries outside the United States, including South Africa (van Staden et al., 2009), the United Kingdom (Pickard, 2012), and Canada (Moola & Krahn, 2018). The scarcity of scholarly attention on professional ballet dancers’ mental health within the United States is concerning given the evidence of emotional distress in similar populations. Counselors may be less than effective without a clear understanding of this population’s mental health needs. Understanding the cultural context and its impact on ballet dancers’ mental health in the United States, therefore, requires further exploration.

Purpose of the Present Study
     The purpose of this study was to explore ballet culture and identity and their impact on ballet dancers’ mental health experiences. The guiding research questions were (a) How do professional ballet dancers define ballet culture and identity? (b) What are the mental health experiences of professional ballet dancers? and (c) What are professional ballet dancers’ suggestions for counseling and advocating with this population?

Method

Given the purpose of this study, we chose a transcendental phenomenological approach as an appropriate method to discover and describe the essence of participants’ lived experiences. Both van Staden et al. (2009) and Moola and Krahn (2018) utilized phenomenological approaches to explore ballet dancers’ mental health and experiences of emotional harm. Originally introduced by Husserl (1970), this approach positions researchers to focus on the individual experience while also identifying commonalities across participants (Hays & Singh, 2012). Further, in transcendental phenomenology, researchers set aside preconceived ideas, seeking to add depth and breadth to people’s conscious experiences of their lives and the wider world. In Moustakas’s (1994) modification of Van Kaam’s method of transcendental phenomenology, researchers aim to collect the experiences of participants while consistently assessing and addressing their biases to produce a purer and transcended description of the researched phenomena. Because our lead author, J. Claire Gregory, possesses a background as a professional ballet dancer, the framework of transcendental phenomenology provided the needed structure for identification of biases and preconceived notions, allowing us to evaluate our positionality to the data.

Research Team Positionality
     Our research team consisted of Gregory, a doctoral candidate and licensed professional counselor, and Claudia Interiano-Shiverdecker, an assistant professor in counselor education and supervision in a CACREP-accredited counselor education program. Gregory is a Caucasian female and was a professional ballet dancer for 7 years. Interiano-Shiverdecker is a Honduran female with extensive experience conducting qualitative research and clinical experience primarily focused on trauma, crisis, and grief. We have a combined 13 years in clinical practice. Moustakas implored researchers to uphold epoché, “a Greek word meaning to refrain from judgment, to abstain from or stay away from everyday, ordinary ways of perceiving things” (1994, p. 85), by bracketing their own opinions, theories, and expectations. Bracketing is a defining characteristic of transcendental phenomenology in which researchers set aside their own assumptions, to the extent possible, to allow individual experiences to emerge and inform a new perspective on the phenomenon (Moustakas, 1994). Given the composition of the research team and the methodology employed, it was vital to engage in ongoing conversations about our collaboration, data collection and analysis, participants, and the data. Therefore, we addressed specific biases by engaging in virtual weekly bracketing meetings for over a year. Before meetings, Gregory would log memos about thoughts during data collection and analysis. Interiano-Shiverdecker would serve as a consultant to address biases. The biases discussed included a desire to not focus on mental health disorders typically discussed in the literature (e.g., eating disorders) and a desire to highlight professional ballet dancers’ strengths to balance out negative stereotypes. Throughout data analysis, we noted that participants discussed other presenting mental health issues and the connection of ballet culture to the development of those issues, including eating disorders. We operated from a social constructivist research paradigm in which multiple realities of a phenomenon exist (ontology), researchers and participants co-construct knowledge (epistemology), and context is valuable (axiology; Hays & Singh, 2012). This approach primarily focused on reflecting the participants’ voices while recognizing our roles as researchers, so we intentionally did not incorporate a theoretical framework to analyze our data.

Sampling Procedures and Participants
     The transcendental phenomenological research procedures we followed included (a) determining the phenomenon of interest, (b) bracketing researcher assumptions, and (c) collecting data from individuals who have directly experienced the phenomenon. Therefore, after receiving approval from our university’s IRB, we used purposive and snowball sampling to recruit professional ballet dancers in the spring and summer of 2020.

Purposive sampling allowed us to select participants for the amount of detail they could provide about the phenomenon (Hays & Singh, 2012). We intentionally recruited individuals who identified as a professional ballet dancer currently or in the past and were 18 years or older, aiming for a sample of at least five participants (Creswell, 2012). The parameters for “professional ballet dancer” were being a dancer with a professional ballet company and receiving financial payment. Gregory emailed potential participants, contacted professional ballet organizations to request distribution of the recruitment flyer among their members, and posted on Facebook groups used by professional ballet dancers. This email and post included an invitation to participate, a link to a demographic form, and an informed consent form. A total of seven eligible volunteers responded to recruitment emails and posts on Facebook groups. Through snowball sampling, we recruited one more participant. Seven of the dancers had worked with the same professional ballet company as Gregory, but only two had danced concurrently with her, which occurred 10 years prior to data collection.

All participants who contacted us about the study stayed enrolled and completed the interview session. Table 1 outlines the demographic information of each participant, with the use of pseudonyms. Five of the eight participants lived in a southern region of the United States, while three participants lived in northwest and eastern regions. All participants identified as Caucasian. Two participants currently worked as professional ballet dancers attached to a company; the other six were ballet teachers, office employees, freelance dancers, students, or nurses.

Data Collection Procedures
     Moustakas (1994) recommended lengthy and in-depth interactions with participants in transcendental phenomenology in order to understand participants’ experiences of the phenomenon and the contexts that influence those experiences. Participation required professional ballet dancers to complete a demographic questionnaire, take a picture that represented their perspective on mental health while dancing professionally, and complete an individual semi-structured interview. We chose to include the picture to include creative expression, a vital element in ballet culture. The use of pictures during the interview process facilitated a representative and safe discussion around mental health. Although we did not directly analyze the pictures, they served as catalysts for interview questions. In qualitative research, photography can supplement primary data collection methods when participants struggle to utilize words alone to capture an experience (Hays & Singh, 2012).

Table 1

Participant Demographic Information

Pseudonym Gender Age Race Professional Status
Abby F 31 Caucasian Former Professional
Cleo F 28 Caucasian Current Professional
Luna F 35 Caucasian Former Professional
Mica F 30 Caucasian Former Professional
Monica F 37 Caucasian Former Professional
Paul M 25 Caucasian Current Professional (Freelance)
Sophie F 33 Caucasian Current Professional
Zelda F 25 Caucasian Current Professional (Freelance)

 

We developed a 9-item open-ended interview protocol (see Appendix) intended to explore participants’ experiences with mental health, counseling, and advocacy. Gregory conducted all interviews, which lasted from 30 to 60 minutes with an average of 40 minutes, and transcribed each interview verbatim afterward. Three interviews were in person, while six interviews occurred over the phone because of the COVID-19 pandemic. During development, we decided to begin with a simple question to help the dancer feel more at ease. In the next five questions, we utilized their picture to discuss mental health. Because the term “mental health” may or may not be known to the dancers, or it may hold stigma, we felt the picture could produce more insight and depth of the concept. Question 6 asked the dancers to consider their social context and its relation to their mental health. We also chose to include a question asking about ballet dancers’ strengths, as this seems to be rare within performing artist and athlete literature. Next, we directly asked the dancers how counselors could help and then asked a final question that created space for any other relevant thoughts. Through these interviews with eight (seven female, one male) professional ballet dancers, we reached data saturation, meaning that no new information emerged in the data creating redundancy.

Data Analysis
     We followed Moustakas’s (1994) modification of Van Kaam’s steps for data analysis, which included (a) developing clusters of meaning, (b) using significant statements and themes to write a description of what participants experienced (textural description) and how they experienced it (structural description), and (c) describing the essence of participant experience from the textural and structural descriptions. First, Gregory engaged in member checking by emailing each participant their interview transcript to ensure accuracy and provide an opportunity to redact any statements. No participant changed their transcript.

Gregory then reviewed each transcript independently, highlighting significant statements or quotes that conveyed participants’ experience. This process is known as horizontalization (Moustakas, 1994). Then, we discussed each identified statement and assigned meaning to similar statements (i.e., clusters of meaning). We used NVivo software for data analysis to ensure consistency, transparency, and accuracy. NVivo, a qualitative data analysis software, aids researchers with consistency in assigning codes to similar topics and allows the research team to cross-check codes for accuracy.

We then determined the invariant constituents, or the final code list, from redundant and ancillary information through a process of reduction and elimination. For example, we eliminated codes that did not illustrate participants’ lived experiences in relation to the purpose of this study. Through the process of reduction, we merged codes if their meaning was similar. These processes allowed us to have a final list of codes that were not repetitive and aligned with the purpose of the study. Using the final codebook, we began the recursive coding process to recode every interview and reach final consensus. Recursive coding, a qualitative data analysis technique, is very useful when analyzing interview data, allowing researchers to compact the data into different categories and illuminating patterns within the data not otherwise apparent (Hays & Singh, 2012). For example, we noticed several codes that illustrated traditions or customs, both positive and negative, that ballet dancers embraced, so we decided to categorize codes about traditions and customs, in both negative and positive categories, to illustrate ballet culture.

Following this initial coding, we explored the latent meanings and clustered invariant constituents into themes, ensuring that all themes were representative of the participants’ experiences. We then synthesized themes into textural descriptions of participants’ experiences, including verbatim quotes and emotional, social, and cultural connections to create a textural-structural description of meanings and essences of experience (Moustakas, 1994). Using the individual textural-structural descriptions, we proceeded to create composite textural and structural descriptions of reoccurring and prominent themes. Finally, Gregory engaged in the member-checking process for a second time by sending the final themes to all participants via email. Four participants responded, all supporting the final themes.

Strategies for Trustworthiness
     To ensure quality, we engaged in multiple strategies to meet trustworthiness criteria, such as transferability, confirmability, dependability, and credibility. Specific strategies included using researcher triangulation, member checking, in-depth description of the analyses, and thick description of the data (Hays & Singh, 2012). Weekly meetings for a year helped reduce researcher bias through openly challenging each other with any conclusions. We also engaged in two rounds of member checking for dependability and confirmability. In addition, we utilized an external auditor with previous experience in qualitative research who was unfamiliar with ballet traditions and culture to aid in establishing confirmability of the results and credibility of our data analysis process (Hays & Singh, 2012). The auditor reviewed our NVivo file for data analysis and notes, and the final presentation of the results in a Microsoft Word document. Although the external auditor provided us with APA suggestions, she had no critical feedback regarding our analysis. Instead, she supported our findings on ballet culture that provided a new insight for counselors. Finally, we used thick description when reporting the study findings to increase trustworthiness. Utilizing thick description allowed us to depict deeper meaning and context of the data instead of only reporting the basic facts (Hays & Singh, 2012).

Results

We identified four prevalent themes about professional ballet dancers’ mental health experiences: (a) ballet culture—“it’s not all tutus and tiaras”; (b) professional ballet dancers’ identity—“it is a part of me”; (c) mental health experiences—“you have to compartmentalize”; and (d) recommendations for counseling and advocacy—“the dance population is unique.”

Ballet Culture—“It’s Not All Tutus and Tiaras”
     All eight participants described ballet as a unique culture with its own set of customs and ingrained traditions. One of the participants, Monica, further elucidated this point: “The traditions of ballet are very old-fashioned, but it’s beautiful when something endures and exists after hundreds of years.” Throughout their narratives, dancers mentioned patterns of “good” and “bad” sides to ballet culture. “It’s not all tutus and tiaras or the perfect life. There is so much beneath the surface,” explained Cleo. To clarify this theme, we divided it into two subthemes: negative aspects of ballet culture and positive aspects of ballet culture. Although we present this theme in two opposing subthemes for simplicity, dancers’ experiences existed along a continuum.

Negative Aspects of Ballet Culture
     All of the participants shared that customs of ballet culture focused primarily on requirements indispensable to successfully performing a job that was emotionally and physically demanding. The dancers’ comments centered around physical body requirements and arduous training, highlighting the need for extreme physical athleticism to perform at a professional level. Monica explained, “They [ballet dancers] have obvious physical strength, stamina, endurance, and mind over matter for what they need to do.” “We’re a very underrated athlete,” echoed Abby. Zelda added, “I would compare us to what the world knows a little bit better as gymnastics for the Olympics.”

Although no interview questions specifically asked about the negative side to ballet, participants shared feeling constant stress, pushing their bodies and minds to their limits, worrying about body image and injuries, and feeling pressure to find and keep employment. It was commonplace for participants to experience a sense of pressure and stress from internal and external forces. For example, Paul stated, “I think about my ballet career, and I think how I was tired all the time, because I would wake up and do so much.” Echoing this feeling, Zelda shared, “I was half thriving, half dying inside.” Other participant statements emphasized feeling mentally broken with the lack of time for any outside hobby and having no power as a dancer. Abby stated, “In ballet, everything was just so competitive and mind twisting. I was raised with the idea that every day is an audition.” She added, “This could be your day, or if you don’t work hard today then 3 months from now it is going to creep up on you. So, it’s this weird, like, permanence that is doomed upon us.” According to Abby, there was a daily pressure to achieve greatness, which at times caused injury. For Cleo, a current professional ballet dancer, employment pressure and injury were prevalent: “I actually had an injury where I was not able to dance for a year. . . . I managed to sprain my ankle in three places. I had spent the entire summer rehabbing and keeping it in a boot.” Yet she explained that because she was “scared [of not being asked to return to the dance school], I danced on it for weeks after the initial injury.” Cleo also saw her peers struggling with the same issue:

My friend had food poisoning yesterday. She is still sick today and they told her she has to come in because they were setting the Adagio scene . . . she literally left class to throw up and then came back to class and the whole time was trying not to throw up.

     Other professional dancers echoed these fears of financial stress and employment stability, which justified their reasons to push their minds and bodies to the limit, despite physical or mental injuries. Despite perceptions of glamour, Paul highlighted the financial strain that most ballet dancers experience by detailing how he made only “$100 a week and lived in a place that charged me $250 a month.” Even with their efforts, three participants had lost their dancing jobs. Luna believed it was her weight that got her fired, while Paul shared, “I would work super hard all day, back to the gym at night, eat super healthy, and I was still fired for not being good enough, according to my old boss.”

Positive Aspects of Ballet Culture
     Despite these intense demands, all participants also discussed positive qualities of ballet culture. These included connection to others, learned adaptability, and creating a story for the audience. Paul highlighted, “Even with the bad parts, there’s a lot more good than there was bad. . . . It’s one of those things, you’re like, I love it so I’ll do it for whatever money.” Monica reflected on her career, saying, “I see fond memories and really good times.” Several participants shared how long training hours and a common goal created a unique connection to others that was difficult to experience elsewhere. Monica passionately stated that “dancers thrive in the sense of community. When you are in a company you are exactly that—part of the greater company and you work together.” Mica shared, “You aren’t really your own person when you are dancing in a professional setting.” “It helps create friends and that was the beauty behind it, you had a support system,” added Luna. Three of the dancers shared their enjoyment of creating an onstage story for the audience. Mica enjoyed how ballet “uses the body to give meaning to stories, more so than other forms of dance.” Luna shared, “We were giving back to the community and being a part of the arts. That was great. I loved that.”

Professional Ballet Dancers’ Identity—“It Is a Part of Me”
     All dancers either directly or indirectly attested to a ballet identity and how it influenced their development. To display the range of experiences, we described this theme in two subthemes: ballet dancer traits and connections to their ballet dancer identities. The first subtheme illustrates aspects that ballet dancers might share, while the second theme discusses how participants connected these traits to their personal identity.

Ballet Dancer Traits
     All participants shared traits they felt were central to life as a professional dancer, such as tenacity and grit, that influenced their identity during and after dancing. Luna, Mica, Sophie, and Zelda mentioned the discipline a dancer must possess for a successful ballet career. “The level of discipline, I think, is unmatched,” Mica fervently stated. Sophie, Mica, Zelda, and Paul mentioned that their determination for continuous improvement represented their role on stage and ability to maintain their jobs. Sophie expressed, “Your determination, your artistic expression, all of those things include the whole person.” The dancers expressed an ability to push through any odds knowing that, eventually, their hard work would pay off. Sophie shared:

Delayed gratification I feel is a big one [strength], especially in a society with everything now being instant and we are always on our phones, but to work on something slowly over time and be patient. Just trust that hard work pays off.

     Dancers indicated a connection between their transformation as dancers and their development as adults. Cleo shared, “If you make it to a professional, you are one of the few that had a hard road, and it makes you have a very thick skin that can help in all matters of life.”

Connection to Their Ballet Dancer Identities
     All dancers expressed both positive and negative emotions about their ballet identity, ranging from gratitude to contempt. Four participants expressed that dancing was not just something they did, it was who they were. For them, ballet, and the culture of ballet, were integral parts of their identity. During her interview, Zelda paused after a question about why she continues to dance and simply stated, “It is a part of me.” Sophie shared, “Over the years, I think I stuck with it because it became wrapped up in my identity a bit. This is who I am, this is what I do, this is what makes me special.” Additionally, Cleo and Sophie identified the power and connection they felt while dancing on stage. This connection gave meaning to their dance career. Sophie shared, “Somehow dance felt like it gave me the most ability to participate in music in a way I really wanted to and a kind of level of expression I never really had.”

Yet four participants also felt that their identity had evolved past ballet. “It’s a picture that represented me at a point in time, but I don’t feel it represents me anymore,” shared Mica. Paul, a freelance professional, shared, “I feel like it definitely was how I viewed myself. But I’m not 100% sure if I do or don’t feel that way now.” Monica, a former professional, explained:

Our identity is who we were and what we had, but that is not my core identity. I know who I am in my identity, and it is in Christ who made me, and also just me as a person is more than what I did and what I do on my days at a job.

Mental Health Experiences—“You Have to Compartmentalize”
     Utilizing pictures to discuss mental health attended to participants’ preferred form of expression. As Zelda stated early in her interview, “I don’t know how to put it into words. It’s hard.” Despite their dedication and passion, all dancers spoke of the demanding nature of professional dancing and its impact on their mental health. Their conversation around mental health focused on two areas: perfectionism and the perfect body and compartmentalization.

Perfectionism and the Perfect Body
     All dancers felt they needed an additional picture to represent the darker side of ballet or related this darker side to imperfections within the picture. Figure 1 displays Paul’s picture of artwork, which the dancer felt represented the outward appearance of perfection but included lumps of paint (i.e., imperfections), a representation of his mental health.

Figure 1

Paul’s Picture of His Mental Health Experience as a Professional Ballet Dancer

 

 

 

 

 

 

 

 

 

     Despite there being no interview questions about their body image, seven of the eight dancers shared thoughts about body image concerns or pressure to develop a certain physique. Throughout their dancing career came numerous hours of practice in front of mirrors. Abby’s chosen picture displayed part of a bathroom mirror: “When I look into the mirror, a lot of judgments come back in, and ballet is all based off of opinions and judgments that really mess with your head.” She added, “Everything revolved around the mirror, and if the mirror said it was ok, then my brain said it was ok . . . with ballet and mental health, I feel like a lot of my mental health was based off the reflection.” Paul also shared, “I was going to the gym every single day and was in really good shape but was still told I was not in ballet shape.” Monica shared another company dancer’s experience: “Even though she was a gorgeous dancer and had the most incredible feet and legs, she was told she was overweight, and she did not know, in those days, how to deal with it.” Luna spoke openly about feelings of depression when she gained weight: “When I got fired, I would go into periods where I gained 20 pounds because of my depression. The whole reason I was fired was because I got too big.” She later added, “I started losing it when I got hired back but was not allowed to be in productions because I was too big. . . . The depression made me eat and go into a dark place.” However, Luna also spoke about current cultural changes regarding the “ideal” body shape for ballet dancers in the United States: “Nowadays I feel that they [ballet companies] have embraced differences in dancers.”

Although participants recognized the benefits of an unbreakable determination, discipline, and rigor toward their professional career, they also noted the emotional consequences of their dedicated work. Cleo best illustrated this point: “It just felt like it didn’t matter how hard I worked, it just took a toll. . . . I thought it [ballet] was beautiful, and 13 years ago I believed this, but then things started to turn darker mentally for me.” Mica shared, “I would say a lot of us, we have anxiety and depression, but we are also crazily mentally strong . . . like me, for example, I was told I was too fat from the age of 12.” With this constant stress, the dancers felt their mental health fluctuated with external forces (i.e., thoughts about not being good enough). Zelda stated, “I had constant anxiety of not being good enough.”

Compartmentalization
     Another prominent subtheme for all of the dancers was compartmentalization. The dancers described compartmentalization of thoughts and feelings as a healthy coping mechanism for some and a hindrance for others. Abby and Sophie spoke about their need to separate from their feelings and thoughts to perform well. Abby told herself, “Do not think that way. You work really hard and you can put all those thoughts into a little box and hopefully, eventually, get rid of it.” She added that “when the thoughts creep up, I try to put them into my little mental box and try not to open it.” Sophie also spoke in depth about how she maintained her mental health and navigated her negative feelings:

I have to separate myself from my feelings sometimes. I have to remember that my feelings aren’t me. . . . You have to believe you can make it happen and it’s going to work out and be resilient enough to take rejection and injuries, and the uncertainty of finances. You have to hold on and believe it will happen for you. . . . Over time I have become more resilient or grounded. My mental health is very dependent on how I take care of the situations I am in.

     However, several dancers also explained how this compartmentalization fostered a negative approach toward mental health, silenced their voice, and led them to bottle up their feelings. Abby described, “If you are sad and can’t handle it, then the director is going to see that, and consequences will happen . . . then it’s the worst . . . we are conditioned to accept whatever is given to us.” Cleo added, “You have to compartmentalize, to hold it in and aren’t allowed to talk about it . . . you’re not allowed to feel the validation of ‘I’m bothered by this.’ It’s almost wrong to feel bothered by this.” When analyzing the data, we noticed that the four participants who were former professional dancers noted an improvement in their mental health after their life in ballet. Sophie also illustrated changes in dancers’ mental health: “It is able to grow and change and be cultivated. So, I do not think mental health as a dancer is fixed.”

Recommendations for Counseling and Advocacy—“The Dance Population Is Unique”
     As the conversation turned toward mental health experiences, all participants expressed recommendations in two areas: counseling and society’s view of ballet dancers and advocacy. 

Counseling
     All participants discussed recommendations for counseling when working with professional ballet dancers. Regarding counseling, Mica shared, “The dance population is unique in itself. A counselor being able to counsel to this is very important.” She further explained, “It’s not the same as advising someone who’s on a basketball team, nor is it the same as advising someone who’s on a theatre crew. It’s just different. It’s an athlete and it’s an artist.”

Abby also urged counselors to recognize trauma among this population: “I think counselors should be aware of emotional abuse and treat dancers as such.” Monica described how ballet dancers joined voices with the MeToo movement: “It just seemed like the movement of women being able to finally express what had happened to them and the abuse they had been enduring was very empowering.” At the same time, she indicated that a lot of people responded with “well that’s just what ballet is.”

Participants highlighted dancers’ absence of mental health services in their work contracts. “Just having someone to talk to would be nice. I know it’s not covered on a lot of health insurances or dancers’ insurance,” said Cleo. “It would be really cool if it were in the context of the studio and dancers could have one session a month at least . . . individual session, group sessions . . . I think a lot of people would jump at the opportunity,” stated Abby. Monica further explained how a counselor could “do a lot to sustain dancers and maybe help their careers because they might be less prone to injury if they aren’t sad and depressed or feeling alone or pushing themselves beyond their breaking point.” She added how counselors may support company staff: “I think there is a lot on the shoulders of the artistic director or one of the ballet mistresses or ballet masters to be an emotional shoulder or a listening ear.”

Another prevalent tenet woven throughout the dancers’ interviews was counselors’ awareness of ballet culture. Three dancers specifically mentioned that if counselors increased their awareness of dance careers, it might help dancers open up to counselors. Paul stated, “I think about when I was dancing, if someone had just been like ‘oh well, you don’t have to be super skinny to dance.’ I’d be like, you don’t know anything, ya know?” Another dancer shared:

Counselors may not need dance experience, but it would be helpful for the dancers if counselors at least have an idea of what a rehearsal day is . . . how many hours we are dancing, how many dancers have second jobs, how often we perform, it adds context . . . having an understanding of the rigors and demands from within the profession.

Society’s View of Ballet Dancers and Advocacy
     At some point in their interviews, all participants described ballet dancers’ mental health as hidden or unknown to society, and therefore believed that the first step for advocacy required awareness. Participants explained that when people go to the theatre to watch The Nutcracker around the holiday season or attend Romeo and Juliet, they see a story, a real-time depiction of magic and narrative. Yet participants felt that this led society to view dancers as having “glamourous lifestyles” or, because of Hollywood, believe that dancers “are frail individuals that do not have a real job, throw their friends down the stairs, and steal husbands.” Cleo openly spoke about the hidden side of the ballet world when sharing her picture:

The idea is that it’s so glamorous and they have this perfect life, it’s like the same way they [society] perceive celebrities and they have these glamourous lives and everything is perfect when you see the surface and the smile you are forced to put on, but they do not see everything that goes on underneath. That’s why I love this photo: you don’t know what the person is actually feeling. . . . On the outside I am a very bubbly person, and people don’t know anything going on behind, I guess behind the curtain.

     Along these same lines, participants advocated for gender equality within the profession. Although no interview questions asked about gender differences, three dancers pointed out this discrepancy by sharing that women are under extreme pressure to maintain their dance careers. Cleo and Abby also identified how most directors were male. Abby expressed this always “trying to appease the person in charge, who is almost always a man.” For five of the participants, the company director played a vital role in how they viewed themselves. Although some dancers noted overall societal changes and awareness that dancers did not have to fit “this anorexic ballerina” stereotype, some felt that overcoming long-lasting traditions in ballet culture of “skinny equals better” required significant change.

Discussion

The purpose of this qualitative study was to provide a better understanding of ballet culture and its impact on dancers’ identity and mental health. More specifically, we sought to explore different facets of professional ballet dancers’ mental health, while also providing cultural context to professional ballet dancers’ lived experiences. Our attention to cultural context is parallel to trends over the past decade reflecting scholars’ increased focus on performing artists’ training environments to understand their experiences (Lewton-Brain, 2012). Using this perspective allowed us to offer recommendations for counseling and advocacy directly inspired by the ballet dancers’ viewpoints.

The findings from this study resemble descriptions of belief systems and practices entrenched in ballet culture previously discussed in the literature (Wulff, 1998, 2008). One overarching premise presented by the dancers was their need to acquire physical strength, stamina, and a “mind over matter” attitude to have successful ballet careers. The positive and negative qualities of ballet culture created a constant push and pull; however, the participants kept dancing. They recognized their hardships and yet believed enduring them was necessary to live their dreams. The ethos of ballet culture made going through hardships—restricting eating, dancing with injuries, and other stressors—worthwhile. Without providing a justification for these physical and emotional injuries, these new findings provide context to understand ballet dancers’ ideas on body, mind, and health. As some dancers shared, ballet was more than a career to them; it was a part of them, and life without it was hard to imagine.

Participant narratives revealed the ballet dancers’ numerous strengths, such as tenacity, grit, learned adaptability, and unbreakable discipline and rigor. At the same time, participants discussed several mental health hardships. To live up to their ballet dancing goals, dancers focused on their most highly used attribute—their bodies. Because of this, body concerns were prevalent in the findings. The dancers also relayed mental struggles and with them a will to succeed and compartmentalize, to carry on for the performance and the art despite physical and/or emotional pain and at times unsupportive or even abusive environments. Their experiences seemed to align with similar concerns shared by tennis player Naomi Osaka and gymnast Simone Biles. To illustrate, Biles withdrew from part of the 2021 Olympics because of a mind and body disconnect. Her decision earned criticism from the public. She later shared her struggles with mental health concerns (i.e., depression) and how stepping down from competition allowed her to prioritize her mental health and protect her body from potential serious injury.

Our findings also aligned with similar results found with elite athletes and performing artists (Åkesdotter et al., 2020; Gorczynski et al., 2017) and ballet literature in other countries that underscore concerns with disordered eating and body image issues that run deep within ballet culture (Clark et al., 2014; van Staden et al., 2009). Participants discussed anxiety, depression, trauma, abuse, and perfectionism. Their discussions indicated a connection, with anxiety and depression feeding into restrictive eating or other types of eating disorders, and an emotional turmoil following when they were unable to have control. Comorbidity between these mental health disorders and eating disorders is prevalent in the literature, and the present findings elucidate a similar connection among professional ballet dancers.

The findings from this study add to our understanding of professional ballet dancers’ mental health across the world by presenting, to the best of our knowledge, the only study within the United States to fully focus on a qualitative exploration of professional ballet dancer mental health experiences. Our findings expand on and reinforce Hebard and Lamberson (2017), whose work implored counselors to advocate for athletes’ mental health awareness. They stressed that athletes are idolized for their physical endurance, and this perception may leave them specifically vulnerable to mental health issues. Our participants expressed a similar concern and desired counseling services integrated into their schedule and provided by a counselor possessing an understanding of the ballet culture and its specific stressors. They believed that mental health services could not only address their mental health struggles and provide trained support, but also reduce physical injuries often caused by repressed feelings of sadness, loneliness, or insecurity. Participants expressed that advocating for this population should focus on increased access to mental health service providers with an awareness of ballet culture.

Lastly, these findings elucidate a need to evaluate aspects of ballet culture ingrained in tradition that can lead to physical and emotional injuries. Conversations about ballet culture and the emphasis on “petite ballerina dancers” are slowly becoming a part of current efforts to dismantle established perceptions of beauty, athleticism, and inclusion. As Pickard (2012) stated about herself as a dancer, “My body is ballet” (p. 25), and participants expressed that for counselors to advocate for and counsel this population, building awareness about this ongoing conversation while acknowledging the impact of ballet culture on professional ballet dancers’ mindset should be a requirement.

Implications for Counseling
     Because of ballet culture and traditions, ballet dancers experience intense physical and mental demands. Counselors must attempt to understand ballet culture as well as its impact on dancer identity and mental health. Counselors need to remain aware of ballet culture when broaching the topic of weight and body identity influences, requirements for a successful ballet dancer, and the relationship between ballet standards and mental health disorders. From the dancers’ perspective, their physical form is directly related to their mental state or how they view themselves. Dancers’ identities intertwine with their bodies from a young age. Although this creates many positive experiences for the dancers, they also expressed how this can lead to depression, anxiety, and other mental health disorders. Considering these experiences, we encourage counselors to support dancers with a client-centered approach and to create an atmosphere of understanding about the dancers’ physical form as integral to their identity and their profession. Utilizing a client-centered approach would allow counselors to inquire about the dancers’ professional experience and help them build an understanding of the professional demands of ballet. Additionally, we encourage counselors to help professional ballet dancers explore their internal self-talk around comparing themselves to others and their relationship with their body.

Although not as prevalent in the data, the dancer statements about abuse are just as vital for counselor awareness. As Monica stated, ballet is a culture with centuries-old traditions and, according to five of the dancers, artist leadership tends to be authoritative in nature. Ballet requires certain physical attributes and training to achieve professional status, which can manifest as abusive relationships and power struggles. We suggest that counselors help professional dancers learn when certain demands may be perceived as abuse by the world outside of the studio. Providing psychoeducation of abuse (e.g., different forms of abuse, power and control wheel) can help ballet dancers differentiate these behaviors and seek help, when needed.

Although many dancers in this study expressed wanting counseling, it seems as though they feared counselors would not understand them or why they committed to such an intense lifestyle. The central need, according to the dancers, is for counselors to be aware of the unique ballet culture. For many dancers, ballet was a part of them, their identity, and something they felt drawn to always be improving. It is not a sport or a hobby, though there seem to be some commonalities between professional ballet dancers and elite athletes. According to the literature (Åkesdotter et al., 2020; Gorczynski et al., 2017), elite athletes experience intense physical demands and elevated anxiety. Our current findings from the dancers are comparable to these features. Therefore, counselors working with dancers may find some similarities with sports counseling. However, counselors should remain aware that sports are for competition and winning, whereas ballet is an art that seeks to provide the audience enjoyment and entertainment.

Limitations and Suggestions for Future Research
     As with all research, limitations exist because of many factors. For example, this study engaged a small, homogenous sample of ballet dancers with limited opportunity to dive deeply into within-group differences. All participants identified as Caucasian and many of the dancers had resided in the same geographical location at one point. We recognize that racial and geographical differences, among others, can significantly impact participants’ mental health experiences.

In addition, seven of the eight participants had experienced a prior dance connection with Gregory. Although this may have contributed to trust and more candid interviews, it is also possible that this resulted in biases despite our measures to ensure trustworthiness (e.g., weekly research meetings in order to bracket).

Another limitation is the ballet dancers’ subjective representation of their own mental health. Their illustrations of their experiences provide an inner look at their mental health yet do not guarantee an accurate or clinical representation of their experiences.

Because of the limited research examining professional ballet dancer mental health experiences, many opportunities remain open for future research. One recommendation is for future researchers to consider within-group differences (e.g., race, gender) through recruitment of a heterogenous sample. Also, considering the study’s participants all identified as Caucasian, we recommend future researchers explore the mental health experiences of minority ballet dancers, as they tend to be underrepresented in professional ballet companies in the United States. Additionally, this study included both former and current professional ballet dancers. Researchers may discover insightful data using a longitudinal study, as this could display information about the career transition period from professional dancer to former professional dancer. Other recommendations for future research include quantitative studies focusing on counseling interventions or prevention. Finally, some participants discussed instances of trauma, depression, and anxiety. Future researchers could examine specific mental health disorders and their comorbidity among ballet dancers by using the GAD-7 (Spitzer et al., 2006) for assessing anxiety and the BDI-II (Beck et al., 1996) for depression.

Conclusion

     This qualitative study explored ballet culture and identity and their impact on professional ballet dancers’ mental health experiences, which resulted in the four themes of (a) ballet culture—“it’s not all tutus and tiaras”; (b) professional ballet dancers’ identity—“it is a part of me”; (c) mental health experiences—“you have to compartmentalize”; and (d) counseling and advocacy—“the dance population is unique.” A distinct culture exists for professional ballet dancers that includes traditions passed down since the 14th century. Hence, tradition, dedication, and commitment to their profession shape professional ballet dancers’ identities. Further, their identities straddle the environments of performing artists and elite athletes, creating contextually distinctive experiences. For counselors to adequately support professional ballet dancers, they must first build their awareness of ballet culture and the unique mental health needs and resiliencies of dancers.

 

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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J. Claire Gregory, MA, NCC, LPC, LCDC, is a doctoral candidate at the University of Texas at San Antonio. Claudia G. Interiano-Shiverdecker, PhD, is an assistant professor at the University of Texas at San Antonio. Correspondence may be addressed to J. Claire Gregory, Department of Counseling, 501 W. César E. Chávez Boulevard, San Antonio, TX 78207-4415, jessica.gregory@utsa.edu.

 

Appendix

Interview Protocol

 

  1. Tell me a little bit about yourself.
  2. Tell me about the picture you took and how this represents your understanding of mental health as a professional ballet dancer.
  3. Is this picture representative of your mental health? If so, how?
  4. What do you see here when you look at your picture?
  5. What are you trying to convey to someone who is looking at your picture?
  6. Describe how this image relates to society and what prevailing ideas about your mental health are present in this picture.
  7. What are some strengths about being a professional ballet dancer?
  8. What can we as counselors do about ballet dancers’ mental health?
  9. Is there anything else you would like to add?

Experience of Graduate Counseling Students During COVID-19: Application for Group Counseling Training

Bilal Urkmez, Chanda Pinkney, Daniel Bonnah Amparbeng, Nanang Gunawan, Jennifer Ojiambo Isiko, Brandon Tomlinson, Christine Suniti Bhat

 

The COVID-19 pandemic resulted in many universities moving abruptly from face-to-face to online instruction. One group of students involved in this transition was master’s-level counseling students. Their experiential group counseling training (EGCT) program started in a face-to-face format and abruptly transitioned to an online format because of COVID-19. In this phenomenological study, we examined these students’ experiences of participating and leading in six face-to-face and four online EGCT groups. Two focus groups were conducted, and three major themes emerged: positive participation attributes, participation-inhibiting attributes, and suggestions for group counseling training. The findings point to additional learning and skill development through the online group experience as well as its utility as a safe space to process the novel experience brought about by COVID-19.

Keywords: experiential group counseling training, phenomenological, COVID-19, face-to-face, online format

 

Most of what is known about group counseling and the training of group counselors has been learned from groups that occur in face-to-face group environments (Kozlowski & Holmes, 2014). This includes seminal works on group counseling’s therapeutic factors, such as universality, altruism, instillation of hope, cohesiveness, existential factors, interpersonal learning, self-understanding, and catharsis (Yalom & Leszcz, 2005). Researchers have found positive contributions of group therapeutic factors toward therapy outcomes (Behenck et al., 2017), and they have explored the experiences of group members in face-to-face group counseling settings, including the interpersonal and intrapersonal processes of members (Holmes & Kozlowski, 2015; Krug, 2009; Murdock et al., 2012). By contrast, there is considerably less research on online group counseling (Kozlowski & Holmes, 2014) or group counselors’ training in online modalities (Kit et al., 2014; Kozlowski & Holmes, 2017).

In this qualitative study, we utilized the phenomenological method to explore and compare master’s-level students’ experiences of participating in and leading during six face-to-face and four online experiential group counseling training (EGCT) groups as part of an introductory group counseling course. The master’s-level counseling students began their EGCT in face-to-face groups, and because of the COVID-19 pandemic, they continued to meet in four online groups after their university decided to suspend all face-to-face instruction.

Experiential Groups in Counselor Education
     Group counseling training is one of the eight core areas of required training for counselors stipulated by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP; 2015). In order to learn the complex group processes necessary for effective group counseling, master’s-level counseling students are required to participate in EGCT (Association for Specialists in Group Work [ASGW], 2007; CACREP, 2015). For CACREP-accredited master’s programs, at least 10 clock hours of group participation during one academic semester are required (CACREP, 2015). During this experiential training, students learn to be both group counseling participants and group counseling leaders (Ieva et al., 2009) and gain valuable experience in and insight into group dynamics, group processes, and catharsis (Ohrt et al., 2014).

Master’s-level counseling students “benefit a great deal when allowed to develop practical and relevant clinical skills” (Steen et al., 2014, p. 236). Experiential training in group counseling also promotes self-awareness, personal growth, and a greater understanding of vulnerability and self-disclosure in the learners (Yalom & Leszcz, 2005). The experiential component of group counseling training provides an environment for counseling students to experience vicarious modeling, self-disclosure, validation, and genuineness from their classmates (Kiweewa et al., 2013). Finally, these experiential opportunities promote students’ self-confidence (Ohrt et al., 2014; Shumaker et al., 2011; Steen et al., 2014).

Online Counseling
     Barak and Grohol (2011) defined online counseling as “a mental health intervention between a patient (or a group of patients) and a therapist, using technology as the modality of communication” (p. 157). Counselors are increasingly using more digital modalities in their practice (Anthony, 2015; Richards & Viganó, 2013), and it is being seen as a viable alternative to support clients (Hearn et al., 2017). Since the start of the COVID-19 pandemic, counselors have begun to use more online modalities to provide counseling services (Peng et al., 2020). Online counseling began to emerge as a potential solution for mental health services when providers were forced to discontinue or scale down in-person services and adjust to virtual formats during the pandemic (Békés & Aafjes-van Doorn, 2020; Peng et al., 2020; Wind et al., 2020). Peng et al. (2020) noted the effects COVID-19 have had on the delivery of mental health services in China. They mentioned the governmental and authorities’ support for preparedness and response and the multidisciplinary enhancement of remote intervention quality for clients. They also suggested that governments should integrate the mental health interventions related to COVID-19 into existing public mental health emergency preparedness and response structures.

Because of the growing importance of online counseling, it is essential to train counseling students to conduct online counseling, including online group counseling, effectively. Understanding master’s students’ experiences in online EGCT can help identify potential challenges they may face during their training. It is also important to explore students’ experiences in face-to-face and online EGCT groups to better understand possible future training needs and help counselor educators create an educational curriculum that addresses group counseling knowledge and skills for online groups. There is currently a lack of information about how to train counseling students in the delivery of online counseling (Kozlowski & Holmes, 2014), and specifically group counseling (Kit et al., 2014).

Professional and Accreditation Bodies’ Guidance on Technology
     The American Counseling Association (ACA) Code of Ethics states, “Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions” (2014, p. 17). The ASGW Best Practices Guidelines require that “Group workers are aware of and responsive to technological changes as they affect society and the profession” (ASGW, 2007, p. 115, A.9). Similarly, CACREP (2015) indicates “students are to understand the impact of technology on the counseling profession” (2.F.1.j) as well as “the impact of technology on the counseling process” (2.F.5.e). CACREP also emphasized that students understand “ethical and culturally relevant strategies for establishing and maintaining in-person and technology-assisted relationships” (2.F.5.d). Additionally, the Association for Counselor Education and Supervision (ACES; 2018) provides guidelines for online instruction featuring descriptions regarding course quality, content, instructional support, faculty qualifications, course evaluation procedures and expected technology standards.

Online Group Counseling
     Textbooks on group counseling have mainly approached EGCT in face-to-face formats (e.g., G. Corey, 2016; Yalom & Leszcz, 2005). Given the growing interest and demand for online counseling in recent years (Holmes & Kozlowski, 2015; Kozlowski & Holmes, 2017), COVID-19 has highlighted the need for greater awareness and understanding of online group counseling training. However, there is limited research on online group counseling and counseling students’ training in online group counseling.

Kozlowski and Holmes (2014) explored master’s-level counseling students’ experience in an online process group, reporting themes of participants’ experiences of a linear discussion, role confusion, and feelings of being disconnected, isolated, and unheard. In 2015, Holmes and Kozlowski expanded on their work with a study on master’s-level counseling students’ experiences in face-to-face and online group counseling training. They found that the online group participants felt significantly less comfortable than participants in the face-to-face group. Further, participants in the study evaluated face-to-face groups as preferable for participation, social cohesion, and security (Holmes & Kozlowski, 2015). Lopresti (2010) compared students’ group therapy experiences between face-to-face and online group counseling methods using synchronous text-based software. This research involved six master’s-level students engaging in an 8-week, 60-minute, weekly online group counseling session using the WebCT chat system. Results indicated that in the online format, some participants reported self-disclosure more easily, but they also shared that it was easy to hide behind the screen and to censor themselves.

Effectiveness of Online Group Counseling
     Some researchers have observed the efficacy of online support groups (Darcy & Dooley, 2007; Freeman et al., 2008; Lieberman et al., 2010; Webb et al., 2008). Haberstroh and Moyer (2012) reported that professionally moderated online support groups could supplement face-to-face counseling, especially for clients who want regular daily support during the process of recovering from self-injury. They also found that online group interaction provided clients with opportunities to engage in healthy self-expression and reduce their sense of loneliness and isolation (Haberstroh & Moyer, 2012). King et al. (2009) examined the effectiveness of internet-based group counseling to treat clients with methadone substance abuse, reporting that internet-based group counseling could reduce resistance and non-adherence in clients. Clients expressed satisfaction with the process and reported convenience and higher levels of trust in confidentiality because they were able to participate from home.

Similarly, Gilkey et al. (2009) reported the advantages and disadvantages of synchronous videoconferencing (SVC) web-based interventions. This study involved families with children with traumatic brain injury. The results revealed that SVC had the potential for family-based therapy delivery. However, it required important factors such as client readiness to address their issues and patience with the technology’s imperfections. SVC could reduce barriers to treatment with motivated families from diverse backgrounds. Nevertheless, the online group experience is vulnerable to the impact of technology glitches, privacy issues, disruptions in connectivity, and personal detachment (Amulya, 2020). In online group therapy, Weinberg (2020) identified four obstacles: managing the frame of the treatment, the disembodied environment, the question of presence, and the transparent background.

Purpose of Study and Research Questions
     In March 2020, as a result of the pandemic, our university moved most face-to-face classes to virtual environments following statewide restrictions for in-person gatherings. This sudden change led to a unique experience for first-year master’s-level counseling students enrolled in an introductory group counseling course at a CACREP-accredited program in the Midwest. It was planned that students would participate in 10 face-to-face EGCT groups of 90 minutes each to fulfill the CACREP (2015) group counseling experiential training requirements. Doctoral students facilitated the first five group counseling experiences for the counselors-in-training. The plan was for two master’s students to lead face-to-face groups under the supervision of doctoral students for the remaining five groups (6–10). However, the university closed for 2 weeks after Session 6 was completed. As a result, when classes resumed, they were online. EGCT Sessions 7 through 10 were conducted online using Microsoft Teams with master’s students leading and doctoral students supervising. Thus, in a single semester, the master’s students had the experience of participating in and leading both face-to-face and online groups. Our study was guided by the following research question: What were master students’ experiences of participating and leading in both face-to-face and online EGCT groups?

Methods

Research Design
     Qualitative methodology was used to explore first-year master’s students’ experiences of participating and leading in both face-to-face and online formats of EGCT. Our aim was to build an understanding of their experience shifting to an online modality with a specific interest in their attitudes, learning, facilitating, and adaptation to these two environments. For this purpose, a phenomenological approach was appropriate for investigating students’ unique experiences in both versions of the EGCT groups. Moustakas (1994) defined phenomenology as an approach for “comprehending or having in-depth knowledge of a phenomenon or setting and . . . attained by first reflecting on one’s own experience” (p. 36). In a phenomenological study, the aim is to describe the essence of individuals’ experiences with a certain phenomenon (Creswell & Creswell, 2018).

Participants and Procedures
     IRB approval was obtained, and purposive sampling was implemented with a recruitment email. All participants were recruited from a CACREP-accredited counseling program in the Midwest  United States. Our inclusion criteria were that participants must be current master’s-level counseling students and must be enrolled in a group counseling course. In addition, each participant must have experienced both participating in and leading at least one EGCT session during the prior term.

The invitation to participate in a focus group was emailed to all students enrolled in the group counseling course in the prior term. It included information about the study, addressed voluntary participation, and explained the entirely separate nature of participation in the focus group from evaluation of performance in the group class that had concluded. This recruitment email was sent out a total of three times within a 3-week period before the study was conducted.

Nine students agreed to participate in the study, and written consent forms were sent to them via email to read and review. Of the nine participants, three self-identified as male and six self-identified as female. Seven participants identified as White and two identified as “other,” and the age range was 18–34 years old. Two participants were specializing in school counseling, three in clinical mental health counseling, three in clinical mental health/clinical rehabilitation counseling, and one in clinical mental health/school counseling.

Before the focus group, prospective participants were emailed a copy of the semi-structured interview questions to alleviate any anxiety or concerns about the questions that would be asked during the study. Prospective participants were also invited to ask any questions at the start of the focus group and were then invited to provide verbal consent. To secure confidentiality, participants were assigned a code consisting of letters and numbers to protect their identity. Participants’ identification codes, with corresponding names, were kept securely in the possession of the first author, Bilal Urkmez.

Focus Groups
     Focus groups were used because they allow students to share their experiences with EGCT groups and compare points of view (Krueger & Casey, 2014). Two online focus groups were held—one with five participants (one male, four females) and one with four participants (two males, two females). Participants received invitation links from the focus group facilitator via Microsoft Teams. All participants were familiar with Microsoft Teams because they had used it for their experiential groups and classes after moving to online instruction. Urkmez contacted the university’s IT department regarding the protocol of recording and securing the video and audio of the focus groups on Microsoft Teams.

Our fifth and sixth authors, Jennifer Ojiambo Isiko and Brandon Tomlinson, who led and supervised the original EGCT groups, conducted the focus groups. Care was taken to ensure that master’s students were not placed in a focus group led by the same doctoral student who had previously led and supervised their 10-session EGCT groups.

We used Krueger and Casey’s (2014) guidelines to create a semi-structured focus group protocol. Open-ended questions were built in for the focus group leaders to use as prompts to facilitate discussion when necessary. The online focus groups lasted approximately 60 minutes. All the conversations were recorded and then transcribed verbatim by the designated focus group facilitator.

Authors’ Characteristics and Reflectivity
     Our research team consisted of two counselor educators with experience teaching and facilitating group counseling courses and five counselor education doctoral students. All doctoral students were part of a single cohort, and all had prior experiences facilitating group counseling. The counselor educators were Urkmez, who self-identifies as a White male, and Christine Suniti Bhat, an Asian female. The doctoral students were Chanda Pinkney, an African American female; Daniel Bonnah Amparbeng, an African male; Nanang Gunawan, an Asian male; Isiko, an African female; and Tomlinson, a White male. Before data collection, we met to discuss focus group questions, explore biases and assumptions, and assign focus group leaders for the study.

Our team used multiple strategies to establish trustworthiness. As two of the researchers taught group counseling and five of the researchers had led and supervised the EGCT groups, it was necessary to discuss possible biases before and during the data analysis process to ensure that the resulting themes and subthemes emerged from participants’ responses (Bowen, 2008).

First, some of the researchers shared that they believe face-to-face group counseling is better than online group counseling because they do not personally like to take or teach online courses in their education. All research members taught, learned, and supervised EGCTs predominantly in face-to-face environments prior to the study and pandemic. Secondly, some of the researchers also mentioned their frustrations with learning and supervising online. These discussions were held to promote awareness of potential biases so as to avoid focusing on the negative experiences of the master’s students. Bracketing was implemented throughout the study to reduce researchers’ possible influence on participants of favoring face-to-face counseling environments (Chan et al., 2013). This measure helped ensure the validity of the study’s data collection and analysis by having the researchers put aside any negative experiences of online learning environments during the pandemic (Chan et al., 2013). Urkmez, Pinkney, Bonnah Amparbeng, Gunawan, Isiko, and Tomlinson analyzed the data first, fulfilling investigator triangulation (Patton, 2015). This same group then met several times to discuss their analyses of the transcripts and agree upon the significant statements and themes.

Experiential Group Counseling Training
     Twenty-eight first-year master’s students were enrolled in an introductory group counseling course in the spring 2020 academic semester. The EGCT groups were a required adjunct to the didactic portion of the course. EGCT sessions for the master’s students met weekly for 90 minutes and were set up so that the master’s students were participants for Sessions 1 through 5 (led by doctoral students) and were leaders for Sessions 6 through 10 (supervised by doctoral students). All 10 sessions were planned to be face-to-face sessions. Doctoral students were enrolled in an advanced group counseling course, and their participation was a required component of the course.

During the first five sessions, doctoral students’ responsibilities as leaders included facilitating meaningful interaction among the participants, promoting member–member learning, and encouraging participants to translate insights generated during the interaction into practical actions outside the group (G. Corey, 2016). For Sessions 6–10, in the role of supervisors, doctoral students’ responsibilities were to mentor and monitor the master’s students’ group leadership skills and provide verbal feedback immediately after the session. Doctoral students also provided written feedback to both the master’s students and group counseling course instructors. Additionally, the doctoral students engaged in peer supervision with each other under the tutelage of the advanced group counseling course instructor, discussing how EGCT could be supervised more effectively.

As stated previously, two master’s students started to co-lead the EGCT groups during Session 6, which was conducted face-to-face. After Session 6, in-person classes were canceled by the university in response to COVID-19, so the remaining four sessions of EGCT were conducted online on Microsoft Teams. The online groups were conducted synchronously on the same day and time as the face-to-face groups had been conducted in the earlier part of the semester.

Session 7 was the first synchronous online session of the EGCT and deserves special mention. Prior to Session 7, the doctoral students received brief training on Microsoft Teams. The master’s students had no previous exposure to Microsoft Teams. Thus, during Session 7, the doctoral students provided support by demonstrating how Microsoft Teams worked and processing the master’s students’ thoughts, feelings, and levels of wellness in relation to the sudden pandemic. Students resumed leading the online synchronous groups for Sessions 8, 9, and 10 under doctoral students’ supervision.

Data Analysis
     Isiko and Tomlinson led the two focus groups and transcribed the data collected from the participants who shared their experiences in the focus groups. We utilized the phenomenological data analysis method described by Moustakas (1994). Urkmez, Pinkney, Bonnah Amparbeng, Gunawan, Isiko, and Tomlinson conducted the data analysis while Bhat served as a peer debriefer because of her position of seniority in terms of expertise in not only qualitative methodology, but also group counseling research, as well as her experience of more than 15 years in teaching both master’s- and doctoral-level group counseling courses at the CACREP-accredited program. Her primary role was to read the transcripts, review the raw data and analysis, and scrutinize established themes to point out discrepancies (Creswell & Creswell, 2018).

Our research team (except for Bhat) met to discuss our potential biases and bracket our assumptions about the phenomenon under investigation. Then, each of us independently read all transcripts multiple times to become familiar with the data. Next, we reviewed the transcripts according to the horizontalization phase of analysis (Moustakas, 1994). Moustakas defined the horizontalization phase as the part of the analysis “in which specific statements are identified in the transcripts that provide information about the experiences of the participants” (Moustakas, 1994, p. 28). During this step, we independently reviewed each transcript and identified significant statements that reflected the participants’ interpretations of their experiences with the phenomenon. We identified these significant statements based on the number of times they were mentioned both within and across participants. From this point, we each independently created a list of significant statements.

Subsequently, we met to review our lists to establish coder consistency, create initial titles for the themes, and place data into thematic clusters (Moustakas, 1994). Each of our themes and related subthemes were similar in content and typically varied only in the titles used. Titles for themes and subthemes were discussed until consensus was obtained. We revisited the horizontalized statements and discussed our different perspectives. Next, we evaluated the most commonly occurring themes and created a composite summary of each theme from the participants’ experiences. After these steps, we arrived at a consensus about each theme’s essential meaning and decided on specific participant quotes that represented each theme.

Findings

We identified three main themes related to the participants’ experiences of taking part in and leading both face-to-face and online EGCT. The three main themes were positive participation attributes, participation-inhibiting attributes, and suggestions for group counseling training.

Positive Participation Attributes
     The central theme of positive participation attributes focused on exploring master’s students’ perceptions about what helped them actively participate in both online and face-to-face EGCT groups as a group member. Five subthemes were identified in the main theme of positive participation attributes: (a) knowing other group members, (b) physical presence, (c) comfortability of online sessions, (d) cohesiveness, and (e) leadership interventions.

Knowing Other Group Members
     The EGCT group involved graduate-level counseling students who knew each other for a semester before engaging in the EGCT. Study participants shared that seeing familiar faces provided a safe and supportive environment for them to participate in both face-to-face and online group sessions as a group member. One participant noted that “a part of it helped because it was many people I had already known,” and another participant stated that “it was easier to have face-to-face after we had already kind of met everybody in the semester and so I wasn’t worried about confidentiality. I wasn’t in this group with a whole bunch of strangers.” Participants noted that knowing other group members helped them to participate actively in EGCT. They reported that having familiar faces in the group made them feel comfortable and connected, and that it helped them engage more fully during the ECGT groups.

Physical Presence
     Study participants shared that group members’ physical presence during the face-to-face sessions enhanced their willingness to participate. The physical presence provided access and a better ability to understand group members’ content and emotion through their body language, eye contact, vocal tone, and other nonverbal cues during sessions. As one participant shared, “I feel so much more in touch and present with people when I can see them, but just kind of feel their physical presence rather than just watching the faces online.” Furthermore, the study participants shared that being physically present during the face-to-face sessions allowed for the incorporation of more icebreaker activities by both doctoral and master’s student group leaders, enhancing their participation in groups. One participant noted that “the small icebreakers, I just remember doing those at the beginning during our face-to-face sessions; those were a lot of fun.”

Comfortability of Online Sessions
     Participants reported that they felt comfortable engaging in online EGCT from their familiar surroundings at home. They appreciated the convenience of participating in ECGT groups from wherever they were. One participant reported that “people could be outside or eating or drinking or whatever, which I think is cool.” Another participant shared that before the state-issued quarantine, they already used online technology to communicate with friends, so it was easy to use Microsoft Teams for online experiential training groups. Another participant noted:

We were doing them (EGCT) from the comfort of our own home; it just increased how comfortable you were in general. We were all at home, rocking in sweatpants and not having to worry about stuff. I feel we were in our own comfortable, safe space, and that made the online easier for me.

Cohesiveness
     Participants reported they felt “anxious,” “lonely,” and “isolated” and experienced other difficulties during the COVID-19 pandemic. They noted that they actively engaged in online EGCT sessions because it provided them with the opportunity to connect, share, and process their thoughts and emotions. A group participant reported, “We all had to isolate. [It] made it exciting to be able to connect with everyone again, to talk about how it (COVID-19) was affecting us, to vent out our emotions and check in with others.” Additionally, another participant reported:

When we started these sessions [online], it was at the beginning of these COVID-19 issues, and I was feeling more stressful, and there was nothing to do. It was so difficult to adjust to this environment, even staying at home. This was like an opportunity for me to connect with classmates in the group and [it] helped me to reflect on my anxiety and how other people were thinking around these COVID-19 issues.

     As a result of the online EGCT groups, participants gained a means of personal interaction during isolation. The subthemes presented above capture the positive participation factors that helped participants to engage actively in both online and face-to-face sessions.

Leadership Interventions
     Participants shared leadership interventions that helped them to participate during face-to-face and online sessions. The sudden transition to online groups due to COVID-19 was characterized by trial and error and uncertainty for everyone. Participants noted that while working with the new online EGCT group and different processes than what they experienced before COVID-19, doctoral students and master’s student leaders demonstrated a sense of flexibility and adaptability to the prevailing situation and could steer the groups in the changing environment. Both the doctoral and master’s student leaders were aware of the effect of COVID-19 on the participants, and they allowed the participants to get support from each other before they could get into the session plan for the group. One participant mentioned that “we kind of partly used that [the group] as a social support group . . . and reflect on how we’re feeling during social isolation.” Another participant shared that “the facilitators were flexible. So, even if they had a topic or something like that, they would allow for flexibility, to check in [with participants], and be able to kind of shift focus to what we all needed.”

Participants explicitly mentioned that the doctoral and master’s students’ leadership interventions, such as encouraging, checking in, and being present, helped them engage in the EGCT groups. Participants highlighted the strength of the group leaders’ encouragement of reflection (“I appreciated that the leader really put emphasis on encouraging us to answer questions”) and overall presence and attention (“[The leader] was attending our behavior and was really good with reflecting”). The participants also found the aspect of “checking in” by the leaders as something that enhanced their participation: “The leaders were always pretty quick to check in on someone if something seemed off.”

Group leaders’ ability to coordinate and successfully facilitate group sessions can significantly influence group outcomes (G. Corey, 2016; Gladding, 2012). Study participants shared that group facilitators demonstrated leadership skills and techniques to facilitate meaningful discussions and participation among members in both face-to-face and online sessions: “Like she [group leader] was always there to answer questions if there is silence; like she didn’t want us to rely on her to do the entire conversation, so her encouragement was beneficial for me.”

Participation-Inhibiting Attributes
     For this main theme, we examined attributes that negatively influenced participation and leading in the online and face-to-face formats of the EGCT groups. Three subthemes were identified: (a) group dynamics, (b) challenges with online EGCT, and (c) technological obstacles for online EGCT. The most prominent subtheme that arose and spread across both group formats was that of the group dynamic. Friction within the group dynamic was one of the primary issues reported by participants. The remaining subthemes were related to challenges with online EGCT groups. These challenges include the importance of “being with” or physically present with the rest of the group, problems with missing nonverbal communication in the online meetings, difficulties navigating awkward silences and pauses in the group, and technical obstacles.

Group Dynamics
     Study participants shared that the group dynamics dictated how much of a connection developed among group members and significantly influenced the progression to the working phase in the groups. In the words of one participant, “I feel like that was definitely something with our group dynamic. . . . There was definitely still good conversations, but I think that impacted it.”

Some participants reported their initial concerns about fostering rapport with group mates chosen randomly for them. Participants expressed thoughts that personalities did not mesh well in their group and that there were issues of building good rapport. Some participants indicated that having a reserved personality made it hard to participate: “For me, it was more about a personal thing because I am an introverted personality, so I find it difficult to talk in groups anyway, so that’s what hindered my participation sometimes.” Another participant stated: “I felt like the others protect themselves by not talking, so why should I open myself and put myself into risk? I thought about that.”

Challenges With Online EGCT
     Participants in this study emphasized that one of the main difficulties of the online EGCT experience that affected their participation and leadership negatively was missing body language and physical cues. Participants shared that they could use nonverbal cues and body language to know when it was a good time to speak without interrupting other group members during the face-to-face ECGT. Because these were missing in online EGCT, the students did not have immediate awareness to participate in group conversation without interrupting other group members. For example, one participant noted the difficulties of “just not being able to read body language as well and not being able to see everyone at once.” As a result of these online environment limitations, study participants indicated they had a sense of “stepping on toes” while trying to participate in online EGCT: “I think that one of the biggest challenges with doing it [EGCT] online is that you want to be respectful and make sure that you are not gonna talk over somebody else.”

Kozlowski and Holmes (2014) previously noted that the unfamiliar environment of online counseling, the time delay because of technology, and the inability to utilize group members’ body language can all create a one-dimensional or “linear” experience in online group counseling environments. These factors appeared to hinder the natural growth and development of the EGCT groups in our study as well. In an effort to reduce the perception of being rude, there were times of awkward silence as participants avoided constant interruptions during the sessions; this difficulty gave the feeling of a linear environment.

One other factor the participants noted in the online format more so than the in-person group was what students described as an awkward silence. This occurrence serves as a subtheme of missed physical cues because the participants noted that the lack of said cues complicated determining when to speak and when to wait: “Online, the silence almost felt like it was much longer than what it really would have been if it was face-to-face.” Another participant stated that they “feel pretty comfortable with silences, but it’s a lot harder to gauge that when it’s online.” This issue presented itself in several circumstances, though one group did attempt to figure out a solution, per the report of one participant: “For our group . . . to help with people talking over each other, we had people type in a smiley face in the chat when they wanted to share.”

Notably, participants in this study also mentioned that there was some physical presence that they could not describe but found to be relevant to them in their connection with the group. Although students were unable to identify it precisely, several study participants agreed on its importance. One participant said that they “enjoy the voice and the video, but I feel like when we are talking, especially in a group dynamic and group processes, especially to grasp something important, I really need to be with this person in a physical space.”

The participants emphasized the importance of physical presence, from the ability to see and greet one another to having space to do activities that got them up and moving. Many participants mentioned some intangible quality they could not name but that was missing when the groups convened electronically instead of in person. A participant shared that “you can observe the body language—what is happening in the group actually, but in online sessions, it’s like you don’t know, you are just talking.”

As noted in other sections, the group members appreciated the space for doing activities together when they were in person. Master’s student group leaders reported that they felt anxious when facilitating icebreaker activities in their online EGCT sessions because of the missing physical presence and noted the loss of face-to-face icebreakers. Study participants lamented that the online format did not allow for these bonding and icebreaking exercises, which when utilized in the usual face-to face format tended to put them in a position to feel better equipped to share with their group members, almost like a metaphorical entryway to the group process: “Some of the exercises are not possible to execute [online] because we were doing some physical things in our group, like throwing balls to each other and stuff.” Without these social warm-ups, the group flow and process suffered; according to those in the focus group, leaders needed more assistance to run activities in online EGCT sessions. One participant added a similar sentiment: “How do we lead a group online with proximity activities or icebreakers we would use? We can’t really do [that] because of the virtual interaction, [it] can’t work.”

Overall, the online EGCT environment limited the interpersonal relationships of the EGCT members and group leaders. Group members could not use their nonverbal communication skills or participate in physical group activities. Lastly, online EGCT appears to provide added pressure on group leaders to keep members engaged during the session. Master’s students had to choose topics where all members felt comfortable enough to participate with minimal encouragement, which was a challenge.

Technological Obstacles for Online EGCT
     Participants reported some technological difficulties that inhibited their ability to participate and lead the online EGCT sessions. Some participants noted that when participants turned off their cameras, it exacerbated disengagement levels within the group and hampered group dynamics. Some speculated that technical difficulties might be an excuse to disengage from the group: “Like in online, I can be mute, I can turn off my camera, I can not talk, and I can accuse the technology for that.” This capacity to disengage negatively impacted the group for several of the focus group participants, who noted that they felt this closed off the group and circumvented the ability to engage with all members of the group.

The limitations of the university-sanctioned online platform used for the EGCT groups, Microsoft Teams, adversely affected engagement during the online sessions as it only allowed four members (at the time of the online EGCT sessions) to be seen on the screen at a time. As one participant stated, “I cannot see all the group members . . . my attention is not with all members. This was difficult. It was difficult to lead the group.” Several group members were vociferous in their dislike for this limitation of the platform. Further, internet connectivity issues were problematic: “Sometimes like a group member would disconnect [because of technology problems], and there would be several minutes before they could come back.” These types of interruptions were frustrating to all group members and group leaders. Master’s student group leaders had a difficult time leading with interruptions.

One focus group participant noted, and others agreed, that it was challenging to learn how to lead a group online because they were missing so many elements of the in-person process of leading a group, and they did not have previous group leadership experience in an online environment. A participant shared that “it’s hard [leading group online]. It’s maybe harder for leaders because they cannot observe what’s going on . . . like body language.” 

Suggestions for Group Counseling Training
     Participants were invited to share their concerns and ways to develop and improve face-to-face and online EGCT group experiences. Three subthemes were identified: (a) software issues and training, (b) identified group topics, and (c) preferred EGCT environment.

Software Issues and Training
     Participants shared common concerns about the software for their online experiential training groups. Specifically, they found Microsoft Teams’ display of only four people at one time prevented them from seeing all group members on the screen. Members who were not speaking were displayed at the bottom of the computer screen with their profile picture or initials, which was not conducive to interaction. One participant suggested that they should “probably just use Zoom instead . . . I like Zoom better, seriously, because I can see absolutely everyone.” Another participant agreed, “But for the reason, at least, in Zoom, I can see everyone’s faces, not, um, not just four.”

Another participant similarly emphasized the importance of seeing everyone on one screen during their meeting: “If you don’t see the faces [at one time], you’re just clueless. I mean, have to, like, awkwardly check in with this person all the time.” Participants also brought another suggestion about training on leading online experiential training groups. Participants shared their anxiety about leading groups using online software because it is a new and unique experience. Because of the sudden onset of COVID-19, the students did not have a chance to get training on how to lead online experiential training groups. A participant mentioned that having training where students could learn how to facilitate online groups before leading weekly sessions would help alleviate anxiety and build competence: “Perhaps allowing a small period where everyone kind of gets adjusted to it and becomes more familiar with it might help facilitate [online] group sessions better.”

Identified Group Topics
     Another suggestion by participants regarding their EGCT experience was using one selected topic for each group. For example, a participant shared: “I think part of what was hard about this that might be something to change is, like having the group just be all over the place in terms of topics from week to week.” Another participant added: “If the group was more, like, a little bit more specific and clearer about like, the goal, or something like that, that might be—might help it flow a little bit better.” Some participants also suggested allowing students to select which group they wanted to attend, instead of having groups pre-assigned to them. In other words, participants preferred to join a specific group based on their interests. A participant mentioned: “I think that would be like a really good option to give like a list of ten types of groups or topics in the groups.” Another participant similarly suggested “giving an opportunity to all students to choose one group. For example, like the one group would work specifically on self-esteem problems or the other one would work on grief problems.”

Some participants noted that they felt there was a lack of purpose for the group, indicating that they were not sure of the group’s goals or objectives and that this hindered their ability to participate fully. Some also shared having confusion about their role and the boundaries of the group and what they could or could not share. One participant noted: “In the first session when we were trying to set up our goals, it was difficult for us to find what the goals will be as a group leader candidate, or as a person.” The focus group participants suggested giving more concrete topics overall for the EGCT group to understand better how to participate. This notion spanned across the online and face-to-face format as a more general recommendation.

Preferred Training Environment
     Lastly, participants were asked about their preference for participation in a face-to-face or online EGCT experience, if given a choice. Even though participants reported a reasonably good experience with online EGCT groups, such as comfortability and cohesiveness, most of the participants voiced a preference for face-to-face sessions if they had to do the group counseling training over again. One participant stated: “Ultimately, face-to-face will probably still be better.” Another participant added: “Face-to-face for sure. I just think as like a profession, we all enjoy working with people. We would prefer to work with someone in person.” Similarly, another participant mentioned: “I would definitely choose face-to-face, but I was thankful that we had the opportunity to do it online.”

Asking the participants about their preferred experiential training group environment garnered the most reaction during the interviews. Most of the participants shared that they preferred face-to-face groups. Even though participants had personal connections in an online setting, they wanted to have face-to-face meetings to interact better. One participant mentioned that “we are doing online sessions right now. I wish that I [could] continue to do the group lab and connect with the group members, but if I have the opportunity to take face-to-face, absolutely, I would do that.” Lastly, another participant added: “Absolutely, it’s face-to-face, but if we are in a situation like this, COVID-19 issues, sometimes the online sessions can be helpful.”

Participants offered their perspectives on learning group counseling skills during the global COVID-19 pandemic. Despite the unprecedented circumstances, the students persevered and completed the course. Group leaders and professors encouraged the group members to participate to the best of their abilities. The concerns and suggestions shared in these focus groups could help counselor educators plan and develop for EGCT in both online and face-to-face formats.

Discussion

This study investigated the experiences of master’s students in an online and face-to-face EGCT group. EGCT is an essential aspect of novice counselors’ preparation and is required by CACREP (2015) standards. In this study, participants identified positive factors related to their EGCT group participation, such as knowing other group members, group leadership skills, physical presence, and connection with other group members. They also reported participation-inhibiting factors such as the complexities of group dynamics, missing physical cues, and technological challenges. Our research findings are similar to Kozlowski and Holmes’s (2014) study on online group counseling training. Their participants reported problems with the group feeling artificial, lacking attending skills, and difficulties with achieving cohesion and connectedness.

In the current study, course instructors and student leaders did not have control over the choice of an online platform. The limitations of Microsoft Teams, which at the time of the online EGCT sessions only allowed four participants to be visible on the screen at one time, added to difficulties with engaging and feeling connected. For participants to remain engaged, leaders and instructors should have access to online platforms that allow students to see all group members simultaneously on the screen. Setting ground rules requiring that cameras remain on during sessions and utilizing the chat feature or the hand-raising feature to facilitate discussions would also help create and maintain a sense of connection. Outlining contingency plans such as the alternatives for not being able to join the group with the camera on are important for successful group outcomes.

Participants in this study appreciated the convenience of participating in online ECGT groups. This is similar to the findings of King et al. (2009) about the convenience of access to online group counseling. In the same study by King et al. (2009), the participants shared that online counseling sessions allowed them to participate from the comfort of their homes, thus improving both convenience and privacy. One of the difficulties participants reported was that of awkward silence. This experience, coupled with interruptions (“stepping on toes”), resulted in students finding that the experience online was more linear and less organic compared to face-to-face interactions. These findings are similar to those of Kozlowski and Holmes (2014). Yalom and Leszcz (2005) noted that the group leader’s role is to design the group’s path, get it going, and keep it functional to achieve effectiveness. Presence, self-confidence, the courage to take risks, belief in the group process, inventiveness, and creativity are essential leadership traits in leading groups (G. Corey, 2016). However, these traits are for in-person groups. It is possible that effectively leading online groups requires other skills that have not yet been identified. The sudden change to online training in this instance did not allow for a planful design. It is necessary for group leaders to possess specific group leadership skills and appropriately perform them to help group members participate in groups (M. S. Corey et al., 2018). However, participants appreciated that the doctoral and master’s student leaders demonstrated flexibility, allowing for additional time to check in with group members and process their experiences and emotions related to the pandemic.

One interesting finding related to how COVID-19 impacted participants’ experiences in the ECGT groups was that group participants actively engaged in the online sessions when they were allowed to process their anxiety and stress due to COVID-19, as it served as a support group. This result is dissimilar to findings of previous studies in which participants felt unsafe during online group sessions and being on online platforms impeded participants’ emotional connection and trust levels (Fletcher-Tomenius & Vossler, 2009; Haberstroh et al., 2007; Kozlowski & Holmes, 2014).

Bellafiore et al. (2003) emphasized online group leaders’ roles as “shaping the group” and “setting the tone.” They also expressed that “establishing and maintaining a leadership style is important in keeping the group going” (p. 211). In the current study, first-year master’s students, many of whom were participating in or leading groups for the first time, had the unexpected and sudden additional layer of learning how to lead online. Further, the abrupt transition from face-to-face to online groups because of COVID-19 did not allow for extensive instructor planning and preparation. Leading groups online was challenging and anxiety-provoking for members, as they lacked experience and were unsure how to proceed. Master’s students need additional training on facilitating online groups, establishing a leadership style, and managing silence. This information corresponds with Cárdenas et al.’s (2008) findings that master’s-level counseling students felt more confident to provide online counseling services after training.

Implications

Although the findings from this study are not generalizable, there may be implications for designing and leading EGCT groups that merit consideration based on the experience of the counselor trainees described in this study. Part of the group design entailed assigning different topics to focus on for each session. The rationale for having different topics for each session should be clearly explained to the participants. Any questions regarding the identified topics should be addressed early to enhance the group facilitation process for both leaders and participants. Additionally, group leaders or course instructors need to explain roles clearly, and group members should understand the group’s boundaries and how they fit with their didactic course.

With online EGCT groups, it is essential to consider how participation is influenced by a lack of natural communication signals, such as body language and physical presence. Counselor educators and EGCT student leaders need to establish ground rules about online group interactions such as having all cameras remain on during sessions, having a private and quiet space from which to participate, and minimizing distractions from pets or relatives, all of which are necessary for successful groups. Further, utilizing technology that allows all members to be seen on the screen may help build connection and cohesiveness. Utilizing methods such as using the chat to insert a symbol or using the hand-raising icon can also help facilitate participation.

Overall, students reported feeling unprepared to lead online counseling groups. However, as counselor educators, we are responsible for preparing our students to engage in online counseling successfully, especially as the COVID-19 pandemic continues into its second year and will continue to affect how much virtual counseling will take place in the future. The recent normalization of online counseling (individual and group) may persuade educators and counselors to “increase their skills in terms of development, comfortability, and flexibility in the online environment” (International OCD Foundation, 2020, p. 1). Therefore, counselor educators should cover online-specific facilitation skills in their training programs.

Limitations and Future Research Directions

This study was the first step in attempting to understand and describe master’s-level students’ experiences of participating and leading in both face-to-face and online formats of EGCT. As with all research, limitations should be considered in interpreting the findings. Further, some of the limitations point to potential research directions.

COVID-19 created a situation where the transition from face-to-face to online formats was compulsory. It is therefore not clear what the experience would have been like if the transition was planned and did not have a situation like COVID-19 in the background pushing the transition, or if the group had been entirely online. Because of unplanned adjustment, course instructors and student leaders did not have control over the choice of an online platform. Outlining contingency plans, such as alternatives when a group member cannot join the group with their camera on, are essential for successful group outcomes, and a lack of familiarity with online platforms may have prevented instructors and student leaders from providing these contingencies and therefore impacted the experience for students.

Further, the EGCT groups were conducted with master’s-level students, and participants already had preexisting relationships with each other. This may have contributed to their strong support of face-to-face groups over online groups. In future research, studies with participants who do not already know each other may help us assess the appeal of online groups to participants. Further, researchers in the future may wish to examine the efficacy of online group counseling training for counseling students compared to in-person group training by comparing two equivalent experiential groups.

The current study recruited master’s-level counseling students from a CACREP-accredited counseling program in the Midwest United States; thus, results cannot be generalized to other institutions. The sample size was small in the current study. Therefore, we caution against generalizing our findings. During the focus groups, participants shared some apprehension about how much information to disclose in group counseling, and they verbalized some confusion on group purpose, direction, or goals. For many, these EGCT groups were the students’ first experience in group counseling training, and this could contribute to them questioning if their feelings and experiences were appropriate (Ohrt et al., 2014).

There are methodological considerations to improve future studies. Focus groups were conducted to collect the data from the participants. In-depth individual interviews would enhance a deeper conversation in understating and reflecting on the challenges and needs of master’s-level students. Participants may have censored some of their true feelings, as they were aware that their group leaders were also part of the research team, even though they did not run the focus groups. We acknowledge that the students knowing each other from previous classes may have influenced how much they shared in groups. Participants in this study expressed comfort with knowing each other from a previous semester. However, it is also possible that students may have disclosed minimal personal information so as not to effect public perception of themselves or effect future professional relationships.

Another area to expand on would be investigating counselors’ self-efficacy while facilitating online counseling groups. For example, exploring positive participation attributes that increase online groups’ participation from the leader’s perspective could be useful. This may allow researchers and practitioners to identify how group counseling can best be leveraged in an online environment.

Conclusion

The purpose of this study was to explore and compare first-year master’s-level counseling students’ experiences of participating and leading in both face-to-face and online formats of EGCT. In summary, students considered that the online format was challenging because it added a layer of learning to their fledgling group work skills beyond the face-to-face setting. Technological barriers that were outside the control of participants inhibited their participation, but on the other hand, the online groups served as a safe and supportive space for students to alleviate their stress and loneliness due to COVID-19. Regardless of the teaching environment, thoughtful and well-planned EGCT groups are essential for student development in this area, and skilled group leaders can manage group dynamics and model group counseling skills. COVID-19 has necessitated a focus on teletherapy and online counseling. The group counseling profession should be proactive in addressing this training need, as conducting online group counseling sessions is likely to continue to be a much-needed skill in a post-pandemic world.

 

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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Bilal Urkmez, PhD, LPC, CRC, is an assistant professor at Ohio University. Chanda Pinkney, MA, CT, is a doctoral student at Ohio University. Daniel Bonnah Amparbeng, MEd, NCC, LPC, is a doctoral student at Ohio University. Nanang Gunawan, MA, is a doctoral student at Ohio University. Jennifer Ojiambo Isiko, MA, is a doctoral student at Ohio University. Brandon Tomlinson, MA, NCC, LPC, is a doctoral student at Ohio University. Christine Suniti Bhat, PhD, LPC, LSC, is a professor at Ohio University. Correspondence may be addressed to Bilal Urkmez, Patton Hall 432P, Athens, OH 45701, urkmezbi@ohio.edu.

Military Spouses’ Perceptions of Suicide in the Military Spouse Community

Rebekah F. Cole, Rebecca G. Cowan, Hayley Dunn, Taryn Lincoln

 

Newly released data from the U.S. Department of Defense shows military spouse suicide to be an imminent concern for the U.S. military. Currently, there is an absence of research in the counseling profession related to suicide prevention and intervention for this population. Therefore, this qualitative phenomenological study explored the perceptions of military spouses regarding suicide within their community. Ten military spouses were interviewed twice and were asked to provide written responses to follow-up questions. Six main themes emerged: (a) loss of control, (b) loss of identity, (c) fear of seeking mental health services, (d) difficulty accessing mental health services, (e) the military spouse community as a protective factor, and (f) desire for better communication about available mental health resources. Implications for practicing counselors and military leadership in helping to prevent military spouse suicide as well as recommendations for future research regarding ways to support military spouse mental health and prevent suicide in this community are included.

Keywords: military spouse, suicide, prevention, intervention, phenomenological

 

     In 2018, there were 624,000 active-duty military spouses in the United States, 92% of whom were female (U.S. Department of Defense [DOD], 2018). Recent data also noted that the average age of a military spouse was 31.5 years and 88% of spouses had postsecondary education (U.S. Chamber of Commerce, 2017). Twenty-four percent of spouses were unemployed (DOD, 2018) and 35%–40% were underemployed (U.S. Chamber of Commerce, 2017). Further, 74% of military spouses had children under the age of 18 and often acted as single parents because of the responsibilities of the service member (Institute for Veterans and Military Families, 2016). And of particular note, the Substance Abuse and Mental Health Services Administration (SAMHSA; 2015) reported that 29.1% of military spouses have had a mental illness, with 11.8% having had at least one major depressive episode, and 6.5% having had a major depressive episode with severe impairment.

Military Lifestyle and Spousal Mental Health
     Military spouses do not serve in combat as service members do, but they are subject to many stressors brought on by the military lifestyle that may affect their mental health (Cole, 2014). One of the primary stressors of the military lifestyle is frequent moving (Tong et al., 2018). Military families move every 2–3 years to a new location (Burke & Miller, 2016), which they may not have adequate time to prepare for, adding to the stress of the relocation process (Tong et al., 2018). Military spouses may feel isolated after moving, as 70% of military families live in civilian communities rather than in military housing (Blue Star Families, 2019). Although social support has been found to be key in ameliorating mental health issues in military spouses (Ross et al., 2020), this support is lost and must be rebuilt when the family moves to a new duty station.

Because of these frequent moves, military spouses are often unable to build consistent careers or finish their education (Institute for Veterans and Military Families, 2016). Relocating spouses may experience difficulty finding a new job or utilizing their professional license or certification in their new home state or country (DOD, 2020b). As a result of these lifestyle challenges, 24% of military spouses are unemployed (DOD, 2018) and 77% of employed spouses have been underemployed at least once (Blue Star Families, 2019). These employment challenges often result in anxiety and depression among military spouses (Linn et al., 1985). In addition, the inability to find work may result in financial stress for the family and often affects spousal mental and behavioral health (Blue Star Families, 2019; Center for the Study of Traumatic Stress, 2020).

In addition to stressful relocations and career disruption, spouses also face frequent deployments of their partners (Allen et al., 2011). These deployments result in increased depression and anxiety in spouses (Baer, 2019; Eaton et al., 2008; O’Keefe, 2016), with 92% of spouses reporting increased stress during a deployment, and 85% reporting that they feel anxious or depressed during a deployment (Romo, 2019). This deployment stress may be amplified when the spouse lives overseas and is away from their friends and family in an unfamiliar culture (McNulty, 2003). When their service member is deployed, military spouses have to take on new roles and responsibilities in the home, which may contribute to these high stress levels (Eaton et al., 2008). In addition, they may live in constant fear for their service member’s physical safety, as they are unable to contact their spouse regularly, or communication may be limited to social media with inherent limits to tone or context that prove to be anxiety-inducing (Allen et al., 2011; O’Keefe, 2016).

Military Spouses and Mental Health Treatment
     Although military spouses are under constant stress in their everyday lives (Cole, 2012; Eaton et al., 2008; Mailey et al., 2018), they often resist seeking mental health treatment (Lewy et al., 2014). Past studies have revealed that spouses often do not seek therapy because they cannot locate a counselor they trust or who understands their culture, they are concerned that someone will find out they are seeking counseling, or they do not know where to find counseling services (Lewy et al., 2014). The stigma that military spouses fear regarding mental health treatment affecting their service member’s career progression mirrors that of the active-duty service member population (Britt et al., 2015). In addition, the pressure that spouses feel to take care of their families without their service member’s support and the sense that they must prioritize their families before themselves has led them to resist receiving mental health help for themselves (Mailey et al., 2018). When they do seek mental health services, spouses are likely to visit their primary care doctor at a military care facility; however, these facilities are not equipped to meet spouses’ mental health needs because of lack of personnel and resources for specialized mental health services (Eaton et al., 2008; Lewy et al., 2014).

Military Spouses and Suicide
     Although many of these studies have focused on risk factors and barriers for military spouse mental health treatment, no research has focused on the consequences of these barriers, including suicide in this population. Although much focus has been placed on researching service member and veteran suicide (Blosnich et al., 2010), statistics regarding military spouse suicide were recently tracked for the first time and released to the public in September 2019 (DOD, 2019). In 2018, 128 military spouses died by suicide, with a suicide rate of 12.1 deaths per 100,000 individuals (DOD, 2020a). Of those who committed suicide, 57.8% were female and 85.1% were under the age of 40. Given the alarming numbers of spousal suicide outlined in the DOD report, it is essential that pioneering research be done to investigate suicidality in the military spouse population. This study, therefore, explored the perceptions of military spouses related to suicide in this population by interviewing military spouses themselves, who are the experts on the military spouse lifestyle and experience (Sargeant, 2012). The purpose of this study was not to focus on the experiences of spouses who have themselves attempted suicide, but rather how members of the military spouse population made meaning of suicide within their community. Thus, a qualitative phenomenological design was appropriate for exploring this meaning making (Christensen et al., 2017; Creswell & Poth, 2017). As experts on their own community and experiences, the participants provided perceptions that proved valuable in understanding the causes and risk factors associated with suicide in this population.

Purpose Statement and Research Questions
     The purpose of this qualitative phenomenological study was to explore the perceptions of military spouses related to military spouse suicide and how these spouses made meaning of suicide within the military spouse community. Based on the perceptions and recommendations of the participants, this study makes suggestions to the civilian and military communities regarding best practices for preventing suicide in and providing mental health services for this population. This study was guided by the following research questions:

  1. What are the perceptions of military spouses of suicide in the military spouse community?
  2. What are the perceptions of military spouses regarding resources to prevent military spouse suicide?

Method

Our research team utilized the descriptive phenomenological tradition in qualitative inquiry, in which the researcher explores the participants’ meaning-making experience and how they translate this experience into their consciousness (Christensen et al., 2017; Creswell & Poth, 2017). In order to gather information and perspective regarding suicide within the military spouse community, Rebekah F. Cole, our team’s principal investigator, interviewed 10 spouses of active-duty service members, using a semi-structured interview, to explore their experiences in-depth and to understand how they make meaning of suicide within the military spouse community. A qualitative researcher does not aim to generalize but to draw out depth of insight from participants; hence, a small sample size was appropriate and justified with the aim of collecting a wealth of information from each participant (Creswell & Poth, 2017). Cole interviewed each spouse two times for approximately 30 minutes over the course of 4 weeks and then sent each participant an email with follow-up reflection questions (e.g., “What was it like for you to participate in this study?”) and demographic questions regarding the participants’ age group, gender, race/ethnicity, military branch, years as a spouse, and spouse’s rank.

Participants
     We selected the participants based on their status as active-duty spouses as well as their willingness and availability to participate in two interviews and complete the follow-up questions. We identified and recruited participants via purposeful sampling following approval by the IRB at our university (Creswell & Poth, 2017). Cole made a posting on a military spouse Facebook page explaining the nature and purpose of the study and asking for volunteers who were married to an active-duty service member. We offered each participant a $250 Target gift card to participate in the study, given to them upon completion of the two interviews and return of the emailed follow-up questions. We selected the first 10 volunteers who responded to the Facebook post as the 10 participants in this study. Once they showed interest in participating in the study, Cole contacted each participant via email to explain the nature and goals of the study and provide the participants with the informed consent document to sign and return.

The participants in this study were all spouses of active-duty service members (see Appendix A for a demographic chart). Three of the participants were Army spouses, three were Air Force spouses, three were Navy spouses, and one was a Coast Guard spouse. Two of the spouses were in the 18–29 age range, five were in the 30–39 age range, and three were in the 40–49 age range. The time spent as a spouse ranged from 1–20 years with a mean of 9.5 years. Eight of the spouses identified as White or having a European heritage and two of the spouses identified as having Asian or Pacific Islander heritage. All of the spouses identified as female. The participants were assigned numbers (Participant 1, Participant 2, etc.) to protect their confidentiality throughout the study.

Research Team
     The research team in this study consisted of Cole and two school counseling graduate students, Hayley Dunn and Taryn Lincoln. These students had been trained in research methodology and were familiar with the qualitative data analysis process. Lincoln is a 35-year-old White female whose husband is a retired service member. Dunn is a 33-year-old White female with no military connections. Cole worked closely with Dunn and Lincoln to review the transcriptions of the interviews, develop a comprehensive codebook, and discuss the themes and patterns that emerged from the data.

Data Collection
     Cole conducted and recorded the interviews via phone. She transcribed the interviews using an automated transcription service and reviewed each transcription word-by-word to verify the accuracy and reliability of the transcription (Creswell & Creswell, 2018; Creswell & Poth, 2017). In each interview, Cole asked questions related to suicide in the spouse population (see Appendix B). She also utilized probing follow-up questions (e.g., “Can you tell me more about that?” or “Why do you think that is?”) to gather additional information throughout the interviews (Creswell & Creswell, 2018). Finally, Cole sent a follow-up email consisting of process questions related to the interview experience (see Appendix B) as well as demographic questions.

Data Analysis
     We analyzed the data in a step-by-step process: 1) organizing the data, 2) looking over all of the data, 3) coding the data, 4) generating a description of themes, and 5) presenting the description of themes (Creswell & Creswell, 2018). Cole first organized the data, sorting each participant’s file and memoing ideas that began to emerge from the data (Creswell & Creswell, 2018; Creswell & Poth, 2017). We then each reviewed the transcripts and email responses in detail. After reviewing the data, we coded the interviews and follow-up questions. Cole compiled the codes that we generated into a codebook. We then identified and defined themes and patterns that emerged from the study. This collaboration continued until we decided that no additional themes and patterns were emerging from the data. Cole then sent the codebook, as well as the themes and patterns, to the external auditor of the study, Rebecca G. Cowan, who confirmed the findings of the research team. Cole then wrote a detailed narrative of the themes, which are presented in the Findings section of this article.

Strategies to Increase Trustworthiness
     In order to increase trustworthiness of the study, Cole, the key data collector in this study, engaged in reflexivity and self-analysis throughout the study (Creswell & Creswell, 2018; Darawsheh, 2014; Meyer & Willis, 2019). As a military spouse and professional counselor, Cole inherently has her own thoughts and feelings related to spousal mental health. Thus, it was important to bracket these thoughts and feelings to prevent them from interfering with the data collection and analysis process. Cole used reflective journaling throughout the study to engage in self-reflection and to increase her self-awareness of her reactions to the participants’ perspectives (Malacrida, 2007; Meyer & Willis, 2019). She also discussed these thoughts and feelings with the research team to explore her position as the researcher in the context of this study (Barrett et al., 2020).

In addition to this reflexivity, Cole kept an audit trail throughout the study, which included the transcriptions of the interviews, the participants’ emailed responses, the codebook, reflexive journal entries, and the notes from the research team (Creswell & Creswell, 2018; Creswell & Poth, 2017). Cowan, an auditor with a PhD in counselor education who has been a counselor and counselor educator for the past 10 years, reviewed the study in full to verify the data collection and analysis process (Creswell & Creswell, 2018) as well as the rigor of the study (Patton, 2002).

To triangulate the study’s data and increase the validity of the study’s results, data were collected through two individual interviews as well as through an email questionnaire, both open-ended forms of data collection (Creswell & Creswell, 2018). Prolonged engagement assisted with the development of trust and rapport (Korstjens & Moser, 2018). Additionally, through the collection of both verbal and written data, the study’s themes gained more credibility, as they emerged from both data sources (Creswell & Creswell, 2018).

Finally, we used member checking (Creswell & Creswell, 2018) to request the participants’ feedback on the credibility of the data (Creswell & Poth, 2017). Member checking allows the study’s participants to become actively involved in and make additions to the data review process (Birt et al., 2016). Cole emailed the participants transcriptions of their interviews and asked them to review and make any additions or changes they would like to the transcriptions, allowing them ownership of their thoughts and words and increasing the trustworthiness of the data (Birt et al., 2016). In addition, Cole discussed the findings of the study with the participants as the themes and patterns emerged (Shenton, 2004).

Results

The study’s data yielded six main themes: (a) loss of control, (b) loss of identity, (c) fear of seeking mental health services, (d) difficulty accessing mental health services, (e) the military spouse community as a protective factor, and (f) desire for better communication about available mental health resources.

Theme 1: Loss of Control
     Each of the 10 participants perceived their circumstances as a military spouse to be out of their control. For example, all of the participants mentioned deployments, especially those on short notice, to be a risk factor for suicide. One spouse described how her active-duty husband “might be home on Thursday and then he’s gone the next day. He finds out on such short notice, that’s really tricky, and a lot of my friends are constantly, you’re just so constantly anxious all the time.”

Four of the participants described how they fear for their spouse’s safety during these deployments, which impacts their mental health. One spouse, for example, described how she lives “just constantly not knowing what’s happening, but then being fearful for the significant other as well.” Another spouse explained how spouses live with a “constant fear of whether or not your spouse will return.” One participant discussed how military spouses are thus more prone to mental health issues:

[T]he stress of your life and the stress you have over your spouse’s military career, whether they’re in danger or not, worrying about their mental health . . . probably aggravates all of the mental disorders that anyone could experience, but just magnifies them if you’re a military spouse.

Participants also felt like they lacked control because of frequently relocating. All 10 participants described the stress involved with moving unpredictably. One spouse described how “you’re always worried about what’s coming next and what you can plan for and what you can’t plan for.” Another participant mirrored this same sentiment: “It’s that ‘Where are we going to be next? We just moved here, but I know in two years we’re going to move again’ type deal . . . always just kind of being on your toes and not knowing what to expect.” Another spouse expressed similar thoughts: “I hope for the best but expect the worst, which is kind of sad, but that is the kind of mentality I’ve had to live by because of how unpredictable this lifestyle is.”

As a result of these constant relocations, spouses are separated and isolated from family and friends, or their “network of support” in the words of one participant. All of the participants recognized the risk of losing this support with regard to their mental health. One spouse, for example, explained the danger of not having “long-standing relationships where you could say like, ‘Wow that person really seems like they’re going through something.’”

Theme 2: Loss of Identity
     All 10 participants struggled with a loss of their identity, especially regarding their careers. Many participants described how career struggles and finding purpose are related to spousal mental health. One spouse explained how “not having that career is part of the anxiety and depression. And not having a purpose in life.” Another spouse described the struggle to maintain a career: “Eventually, it kind of weighs on you and eventually your mind can play tricks on you and you feel like you’re not worthy.” One participant summed up these career struggles in these words: “Part of being a military spouse is sacrificing your own life . . . there’s a lot of hurt and loneliness and sacrifice.”

In addition to this struggle for career identity and purpose, five of the participants described how the military fails to recognize their value. One spouse described how spousal suicide “is definitely brushed under the rug because people are kind of like, ‘You’re not going to war, you’re not doing any of these things.’” Another participant described her own experiences: “We’ve had situations where wives were struggling, but . . . he couldn’t get off that day, he had to report in because she’s not at the hospital . . .it’s not serious.” Another explained how “the military in general, they’re so focused on their job that they kind of forget that we’re all humans and that we are people.” One participant said that “spouses get beat down and they just kind of feel like there’s the whole ‘If the military wanted you to have a family, they would have issued you one.’”

The participants also described the military spouse’s tendency to prioritize family and the military over oneself and the impact of this inclination on spouses’ mental health. “So much of the burden of the family falls onto the military spouse, I think it’s easy for the spouse to not consider their own mental health a priority, and therefore the risk factors may go undetected or untreated.” Another described how spouses “go through this constant cycle that’s always churning. You move to a new place, you try to get settled . . . then we hit the point of going, ‘Ok, now what about me?’ If we ever get to that point.” One spouse described that after each of the moves and deployments, “I feel like we lose a sense of ourselves too . . . it’s like having a new baby all of the time. . . . You kind of reach a point where you’re like, ‘Where am I? What the heck am I doing?’”

As a result of prioritizing family and the military over themselves, spouses feel unworthy of receiving mental health services and feel guilty for suffering, as described by eight of the participants. One spouse explained that “spouses can feel weak or feel like they’re not holding up their end of the bargain if they get help.” Another participant noted that spouses “consider themselves less worthy of getting treatment or that their problems [are] not as important.” Finally, a spouse explained that there is a “weird mentality, I think, in the military spouse community, where you don’t complain because someone else has it worse. . . . If you’re an Air Force spouse, maybe the Army deployments are longer, so you just don’t want to complain.”

Theme 3: Fear of Seeking Mental Health Services
     Despite these challenges that military spouses face, eight of the participants described a fear of seeking out mental health services. Five of the participants, for example, said that spouses fear appearing to be unstable or, as one spouse described, a “fear of being ostracized, or the fear of having people talk behind your back, or embarrassment.” One spouse explained how mental health issues are viewed as, “Oh, she was a crazy spouse. Oh, she got everything that she needed . . . so she was just kind of crazy.” Another participant described how a spouse was viewed after verbalizing her mental health struggles: “I’ve been told by other spouses not to go hang out with her in group settings because she’s batshit crazy.” One spouse noted that “there’s still that stigma of reaching out and being known to have the mental health issue.” Finally, spouses may fear being honest with their medical providers for this same reason. One participant described her own perception of this fear of being transparent with the doctor regarding a suicidal assessment: “If you answer it honestly, sometimes you’re like ‘They’re going to put me in a padded room if I really tell you what my last 2 weeks has been like.’”

In addition to appearing unstable, seven of the participants described how military spouses fear that seeking mental health services would negatively impact or bring “backlash” on their service member’s career. One participant noted: “People keep it quiet because they don’t want their spouse, their military member, to not get promoted or not get more responsibility and stuff like that because they’re not keeping it together.” Another participant stated that often “you run into people who are kind of skittish about going just because of the stigma.” She further explained that “you don’t want to hurt your husband’s career, and that’s what you’ve heard for a long time. He looks like he can’t handle the situations at home.’”

Theme 4: Difficulty Accessing Mental Health Services
     Spouses who do decide to seek help for their mental health may experience difficulties in securing an appointment, as described by six of the participants in this study. Each of these spouses expressed difficulties with finding a mental health provider in the community or accessing mental health treatment at a military facility. One participant explained that “the reality is they can’t guarantee that the local community and local providers will be able to provide everything we need when we need it.” Another spouse expressed frustration that “TRICARE can sometimes be a pain when you’re trying to schedule something, and it will make you schedule at 6 weeks out because that’s the first available.” One participant described her experience with trying to find a counselor covered by TRICARE. She stated, “You hope that you get an appointment and hope you can jive with whoever you called because you may have to wait another month or two to try to find someone else.” Three spouses in the study also expressed concern about the consistency of care due to frequent relocations. One participant explained the need to streamline mental health services at each duty station “so that if [spouses] are seeing a psychiatrist in one place and they go to the next place, they’re not waiting for 2 or 3 months before they can get in to see a new psychiatrist.”

Five of the study’s participants also expressed concern over not having access to a mental health specialist. For example, one spouse shared that “the person I did see, who was a social worker, I just don’t feel was very equipped to talk to me about the things I wanted to talk about.” Another spouse described her perception of military family life consultants’ work with spouses on military bases:

They just kind of give them the same spiel, like you should exercise, make sure you’re eating well, getting enough sleep, instead of saying, “You know what? This is outside of the realm of what I can handle, let’s get you in to the type of professional that you need.”

Theme 5: The Military Spouse Community as a Protective Factor
     In the midst of these mental health challenges and difficulty seeking and accessing mental health services, seven of the participants described the military spouse community as a protective factor against suicidal ideation. As one participant explained, “Anyone can try to take their own life, but if they have people around them who are looking out for them, who are with them physically and emotionally, it’s harder to do.” In addition, one participant pointed out that the spouse community can offer a sense of shared understanding: “Someone else probably very close by has gone through the same thing that you have . . . and you’re not the first person to go through this and someone might be able to help lighten your load.” The participants emphasized the need to create “a friendly, inclusive environment where spouses can network and establish relationships” as well as establish a “connection and feeling of belonging.” One participant noted that within this environment and community, it is important to normalize conversations about mental health in order to decrease the stigma attached to it. “Letting people see that while we might post pretty pictures on Facebook and someone looks all together when they’re at that unit function, we’ve all had to reach out for help, and looking at that as being strong.”

To increase this protective factor as a community, six spouses described the importance of training for spouses geared toward suicide prevention so they could recognize the signs of suicide in others. One spouse said that training in “prevention measures of how to spot suicide, signs of suicide, or who to talk to, where to go, what to say” would be helpful “because spouses are probably already witnessing all of these signs in their homes or in their neighbors or in their friend groups of depression and suicidality.” Another participant described how “spouses could be looking out for friends, if they know some warning signs or give friends resources to go to so their friend could find it if they need help.”

Theme 6: Desire for Better Communication About Available Mental Health Resources
     Each of the 10 participants expressed the need for the military to communicate more with them about mental health resources. One spouse, for example, pointed out that such “information needs to be put out there clearly at military hospitals, on military bases. . . . So I think the military could make it more clear, destigmatize it, and just make the programs more widely available and advertised.” In this proposed advertisement, the spouses would want to know “what kind of help we can get, what it costs, where we can get help, and will it matter to our spouse’s career?”

In addition to this suggested advertising, six of the participants said they would like the military leadership to communicate with them directly regarding available mental health resources specifically designed for spouses. One participant described how “it’s harder for the spouse to get that information . . . if they had information sent directly to them, I think they would be more willing to seek it out and use those resources.” Another spouse noted that “military spouses need to be presented with the resources available for their mental health directly instead of solely relying on the service member to relay the information.” As a result of receiving this information on resources available specifically for them, one participant explained that “the military spouse wouldn’t have to consider themselves less worthy of getting treatment or that their problems [were] not as important.”

Finally, six of the spouses suggested that the check-in process for each duty station could be a key opportunity to provide spouses with resources and preventative services. One spouse noted: “I think that when you move somewhere new there should be someone checking to make sure you’re okay and you’re not alone all the time. I think it’s the military’s responsibility to make sure there’s a process in place.” Another spouse proposed this check-in process as being “part of the standard procedure to make sure the spouse maybe is brought in and made aware of all of the programs that are available to them.”

Discussion

     In this study, all of the military spouse participants described how spouses’ loss of control and loss of identity may contribute to their increased risk for suicide. These feelings resulted from continually moving to new duty stations (often unexpectedly), being isolated and separated from their support systems, fearing for their spouse’s safety during deployments, and struggling to maintain a sense of self and a career while making their families and the military their priority. Although they were committed to prioritizing the military lifestyle and their spouses’ career, these spouses did not feel that their needs were prioritized by the military in turn.

Each of these challenges for military spouses has been previously addressed in the professional literature (Eaton et al., 2008; Lewy et al., 2014; Mailey et al., 2018), although their direct correlation to suicidality has not yet been explored. Because increased levels of suicidality have been found in other populations when social isolation increases (Calati et al., 2019; Heuser & Howe, 2019; Pompili et al., 2007) or stressful life transitions or events occur (Oquendo et al., 2014; Paul, 2018), it is important to continue to consider how these risk factors impact military spouses’ suicidality.

Most of the participants likewise described the tendency of spouses to feel guilty for suffering, as they are not the ones on the battlefield, a new phenomenon not yet explored in the professional literature. One participant concluded that these feelings of guilt may lead to spouses feeling they are unworthy of using mental health resources intended for active-duty service members. To address these feelings of guilt, one spouse described the need to normalize the conversation about mental health among spouses, which would ameliorate these feelings of unworthiness and increase spouses’ use of resources. Finally, all of the participants felt that provision and advertisement of mental health and suicide prevention programs and services specifically for spouses would help them feel more confident in utilizing these services.

When speaking about risk factors associated with suicide, most spouses described their fears of the stigma associated with accessing mental health services and the struggles associated with finding mental health providers qualified to help them when they did decide to seek help. These fears and struggles directly correspond to results in past quantitative and mixed-methods research regarding barriers to treating military spouse mental health (Eaton et al., 2008; Lewy et al., 2014). The participants in this study likewise described their frustration with not being able to get an appointment with military or community providers. These struggles echo the results of previous research describing the challenges of spouses to access mental health services (Lewy et al., 2014), highlighting the consistency of this issue.

Although the participants’ struggles with mental health and mental health providers confirm the findings of existing studies, their suggestions for preventing suicide within the military spouse community are new ideas generated from this study. Primarily, the participants focused on the community itself as a protective factor against suicide. They described how building a strong spousal community prevents feelings of isolation, as spouses can care for each other because they share common experiences of the military lifestyle. This sense of connection is especially important, as spouses are separated from their support systems when relocating from one duty station to the next (Ross et al., 2020). In order to strengthen the protective factor of their community, the spouses discussed how they wanted more training from military leadership in the areas of suicide prevention and intervention so that they can help others around them. Interestingly, contradictory themes arose in this study’s findings regarding the spouse community shunning those who were struggling with mental health issues and the spouse community serving as a much-needed protective factor. Perhaps the participants’ suggestions of focusing on normalizing mental health support within their community would help to reduce the current tendency to shun and would increase the tendency to support.

In addition to focusing on increasing the protective factor of the spouse community itself, all of the participants stated that they desired increased communication from the military regarding mental health services and programs available specifically to them. Some of the spouses suggested that a direct line of communication from military leadership to spouses would be helpful for finding out about mental health resources available to them, as well as to their spouses. This communication would involve more strategic and widely spread advertising about suicide prevention resources and mental health services in places that spouses often frequent, such as military hospitals or on-base/on-post facilities.

Finally, several spouses suggested an innovative, structured check-in process at each duty station that would promote spousal awareness and understanding of the resources available to them. They explained that this check-in would provide an immediate sense of connection and community for the spouse and a way to formally network with other spouses in the area. This formalized check-in process carried out by the administration at the new duty station may be especially helpful for newer spouses who may not be familiar with the military’s mental health resources or health care system or who may be hesitant to reach out on their own to make connections with others, a pattern noticed by three of the most senior spouses in this study.

Implications for Future Training and Practice
     Both the military community and the mental health counseling profession are called to recognize the mental health struggles that military spouses face in order to help prevent suicide in this population. Military leadership should strategize ways to provide easier access to mental health services for spouses, including suicide prevention programs designed specifically for this population. In addition, suicide education programs for spouses may help them identify warning signs in others, ultimately strengthening the protective factor of the military spouse community. Military leadership should also work to reduce the stigma of receiving mental health services, not only for active-duty service members, but for their family members as well. Military leaders may likewise consider the participants’ suggestions regarding direct communication between military leadership and spouses, including a formalized check-in process for each duty station. Each of these suggestions offers a solution to the challenges outlined by both the professional literature and the spouse participants in this study regarding the mental health challenges faced by spouses and the risk factors of military spouse suicide.

Next, mental health counselors are called to be aware of and screen for the risk factors for suicide in the military spouse population that may be correlated to the inherent challenges that the military lifestyle brings. As prevention is a primary focus within the counseling profession (Sale et al., 2018), counselors might create preventative, psychoeducational groups for spouses to enhance their sense of connectedness and wellness. These groups would serve to identify spouses who may need additional supportive services to mitigate risk of depression and anxiety as well as other mental health issues. Additionally, when relocations occur, counselors should consider connecting their military spouse clients with mental health services in their new location and, with the permission of the client, reach out to those providers to ensure continuity of care. Finally, mental health counselors should actively seek out and build partnerships with military leadership in order to develop evidence-based resources specific to preventing suicide in the spouse population and to reduce the mental health stigma present in both active-duty service members and spouse communities.

Limitations
     Several limitations to this study exist related to the nature of qualitative methodology. First, in qualitative research, the researcher is the primary source of data collection and analysis. Thus, inherent biases exist throughout this data collection and analysis process (Anderson, 2010). However, bracketing and reflexivity reduced the potential impact of this limitation. Additionally, because mental health stigma exists within the military community, it is possible that participants were guarded during their interviews. Prolonged engagement assisted with mitigating this limitation. Finally, because of the nature of qualitative research, the sample size of the study is small (Atieno, 2009). For instance, the sample in this study did not include the perspectives of any male spouses or spouses who are African American or Hispanic. Additionally, although the sample includes Army, Navy, Air Force, and Coast Guard spouses, no Space Force or Marine Corps spouses are represented. Because of these limitations in gender, ethnicity, and branches, the sample is not representative of the military spouse community as a whole.

Implications for Future Research
     Given these limitations of qualitative research, future quantitative research might focus on specific causes of suicide among military spouses. For example, studies might look at the characteristics of spouses who have committed suicide to detect any patterns or correlations that may exist. There should be particular focus on exploring any ethnic, racial, sexual minority, or gender identity disparities. Future researchers could pilot training programs in the military aimed at preventing military spouse suicide to develop best practices in this area. Finally, future qualitative studies should focus on the experiences of male military spouses. This is critical as the male military spouse suicide rate was recently found to be statistically higher than the overall male suicide rate in the U.S. population (40.9 per 100,000 and 28.4 per 100,000, respectively; DOD, 2020a).

Conclusion
     Overall, the military spouses’ perceptions of risk factors for suicide in this study align with previous studies regarding military spouse mental health that have been conducted throughout the past 12 years. With a new knowledge of the number of spouses that are committing suicide, it is imperative that both the counseling profession and military leadership continue to work toward solutions for spousal mental health. These stakeholders are called to recognize the inherent risk factors of the military lifestyle and provide military spouses with the resources, training, and services that they need (and want) to address and prevent suicide within their community.

 

Disclosure and Disclaimer Statements

This research was partially funded by a faculty research grant from Arkansas State University.

The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense.

This research protocol was reviewed and approved by the Arkansas State University Institutional Review Board (IRB) in accordance with all applicable Federal regulations governing the protection of human subjects in research.

Neither the authors nor their family members have a financial interest in any commercial product, service, or organization providing financial support for this research.

 

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Appendix A
Demographics

Participant Age Group Gender Race Military Branch Spouse’s Rank Years as Spouse
Participant 1 30–39 Female White Army Officer 10
 

Participant 2

 

18–29

 

Female

 

White

 

Army

 

Officer

 

1

 

Participant 3

 

30–39

 

Female

 

White

 

Coast Guard

 

Enlisted

 

11

 

Participant 4

 

18–29

 

Female

 

White

 

Navy

 

Officer

 

3

 

Participant 5

 

30–39

 

Female

 

Asian

 

Air Force

 

Officer

 

2

 

Participant 6

 

40–49

 

Female

 

White

 

Army

 

Officer

 

20

 

Participant 7

 

40–49

 

Female

 

Asian

 

Air Force

 

Officer

 

20

 

Participant 8

 

40–49

 

Female

 

White

 

Air Force

 

Officer

 

18

 

Participant 9

 

30–39

 

Female

 

White

 

Navy

 

Enlisted

 

8

 

Participant 10

 

30–39

 

Female

 

White

 

Navy

 

Officer

 

2

 

Appendix B
Interview Protocol

First Interview

What are your perceptions of suicide in the military spouse community?

What are the risk factors for suicide in the military spouse population?

What mental health challenges do military spouses face?

What resources currently exist to help prevent military spouse suicide?

What would you like to let the civilian world know about your life as a military spouse that they might not be aware of?

Is there anything else you would like to add?

Second Interview

Do you have anything else to add from our first interview?

What do you think causes military spouses to commit suicide?

What needs to be done to prevent suicide in the military spouse community?

What might be the consequences of not addressing suicide in the military spouse community?

What type of mental health support is most needed for the military spouse community?

How would your mental health differ, if at all, if you weren’t a military spouse?

Is there anything else you would like to add?

Follow-Up Email Questions

Is there anything else you would like to add to your interview responses?

What was it like for you to participate in this study?

What is the most important resource that military spouses need to prevent future suicides?                                                             

 

Rebekah F. Cole, PhD, NCC, LPC, is formerly an assistant professor at Arkansas State University and is now a research associate professor at the Uniformed Services University. Rebecca G. Cowan, PhD, NCC, BC-TMH, LPC, DCMHS, is a core faculty member at Walden University. Hayley Dunn is a graduate student at Arkansas State University. Taryn Lincoln is a graduate student at Arkansas State University. Correspondence may be addressed to Rebekah Cole, Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, 4301 Jones Bridge Rd., Bethesda, MD 20814, rebekah.cole@usuhs.edu.

Mental Health Counselors’ Perceptions of Rural Women Clients

Lisbeth A. Leagjeld, Phillip L. Waalkes, Maribeth F. Jorgensen

Researchers have frequently described rural women as invisible, yet at 28 million, they represent over half of the rural population in the United States. We conducted a transcendental phenomenological study using semi-structured interviews and artifacts to explore 12 Midwestern rural-based mental health counselors’ experiences counseling rural women through a feminist lens. Overall, we found eight themes organized under two main categories: (a) perceptions of work with rural women (e.g., counselors’ sense of purpose, a rural heritage, a lack of training for work with rural women, and the need for additional research); and (b) perceptions of rural women and mental health (e.g., challenges, resiliency, protective factors, and barriers to mental health services for rural women). We offer specific implications for counselors to address the unique mental health needs of rural women, including hearing their stories through their personal lenses and offering them opportunities for empowerment at their own pace.

Keywords: rural women, mental health counselors, feminist, perceptions, phenomenological

 

More than 28 million women, ages 18 and older, live in rural America and represent over half of the rural population in the United States (Bennett et al., 2013; U.S. Census Bureau, 2010). Researchers have discussed women’s issues as a distinct category within counseling for over 50 years, yet few counseling programs offer training specific to counseling women (American Psychological Association [APA], 2018; Broverman et al., 1970; Enns, 2017). Rural women have garnered even less attention within counseling literature and training over time (Bennett et al., 2013; Fifield & Oliver, 2016). In addition, rural mental health researchers have focused on rural populations in general, encapsulating women under the entire family unit (U.S. Department of Agriculture, 2015). However, in all environments, women experience mental health needs in unique ways (Mulder & Lambert, 2006; Wong, 2017). Although government agencies have increased efforts to alleviate mental health disparities in rural areas, there is limited research available on rural women’s mental health to guide these efforts (Carlton & Simmons, 2011; Hill et al., 2016). Thus, more studies focused on rural women can assist in comprehensive data-based decision-making efforts of federal, state, and local policymakers (Van Montfoort & Glasser, 2020). Mental health counselors who work with rural women have a unique perspective in understanding the needs of rural women and the disparities they face.

The Invisibility of Rural Women’s Mental Health
Researchers have described rural women as invisible within the mental health literature. Specifically, they have used words such as “unnoticed,” “lack of recognition,” “overlooked,” and “no voice and no choice,” which may illuminate why rural women have less access to appropriate mental health services and may underlie the noticeable absence of rural women as participants within research (Mulder & Lambert, 2006; Weeks et al., 2016). Members of rural communities have traditionally seen women as an extension of their nuclear and extended families and as responsible for involvement in community and church activities (Mulder & Lambert, 2006). Rural women, as a population with unique mental health needs, may need help (i.e., representation in research) getting their voices heard on a more macro level to promote systemic changes (Van Montfoort & Glasser, 2020). A research approach based in feminist theory may amplify the voices of rural women (Schwarz, 2017).

Feminism is a theoretical approach that evolved following the women’s movement in the 1960s, and grew to effect change in social, political, and cultural beliefs about women’s roles (Evans et al., 2005). Many of the early feminist writers spoke of women as “oppressed” and “having no voice” (Evans et al., 2005). Those words have been similarly found throughout the literature on rural women (Weeks et al., 2016). Feminist theory has traditionally challenged the status quo of the patriarchy by working to reduce the invisibility of women’s experiences (Evans et al., 2005; Schwarz, 2017). Further, feminist theory has evolved to amplify voices of all oppressed and marginalized individuals and to promote recognition of the intersectionality of identity. The feminist perspective can facilitate insight into the context of rural women’s experiences (Wong, 2017).

Challenges Faced by Rural Women
The definition of rural areas has historically been based on population size (U.S. Census Bureau, 2010). Some consider rurality a more accurate term than rural, as it may include population density, economic concerns, travel distances to providers, religion, agricultural heritage, behavioral norms, a shared history, and geographical location (Smalley & Warren, 2014). Rural women face unique needs related to the intersection of gender with race, ethnicity, age, and sexual orientation (Barefoot et al., 2015). Rural women have less access to educational opportunities, are often the head of household, and are more likely to live in poverty than urban women (Watson, 2019). Lesbian and bisexual rural women face challenges of bias, lack of support, and increased victimization (Barefoot et al., 2015). Although urban women also experience mental health issues related to motherhood, rural women often must travel long distances to services and have limited access to postpartum care (Radunovich et al., 2017). Residents in many rural communities experience food insecurity and related disordered eating with less proximity to grocery stores and limited food choices (Doudna et al., 2015). Isolation also creates a greater risk for partner abuse that is complicated by long distances to shelters, lack of anonymity, and a widely held view of traditional gender roles (Weeks et al., 2016). The lack of research regarding rural women and mental health compromises the efforts of rural counselors to provide care that is culturally responsive and efficacious (Imig, 2014). In addition, the recognized barriers of accessibility, availability, and acceptability of mental health services in rural areas disproportionally affect rural women (Radunovich et al., 2017).

Barriers to Mental Health Services
A lack of professionals, limited training for work in rural areas, high rates of turnover of mental health professionals, and limited research about rural demographics can negatively impact the quality of services (Smalley & Warren, 2014). In addition, rural residents may experience barriers such as long distances to services, adverse weather conditions, affordability of services, and a lack of insurance coverage (Smalley & Warren, 2014). Rural women may also feel reluctant to seek out mental health services for fear of loss of anonymity and the stigma attached to seeking mental health services in rural areas (Snell-Rood et al., 2019). Approximately 40% of rural residents with mental health issues opt to seek treatment from primary care physicians (PCPs), as these professionals may represent the only health care provider in the area (Snell-Rood et al., 2017). However, these professionals often have limited expertise in diagnosing and treating mental health issues (Hill et al., 2016).

Currently, the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) does not specify rurality or other cultural identities when referencing cultural competence within required curriculum. This omission may contribute to minimal specialized training, in addition to the limited research for mental health counselors to use as a guide for understanding the unique needs of rural women (Watson, 2019). Additionally, agencies have difficulty recruiting mental health counselors because of isolation from colleagues and supervisors, lower salaries, limited social and cultural opportunities, and few training opportunities specific to rural mental health (Fifield & Oliver, 2016).

Addressing Mental Health Needs of Rural Women
Given the limited research about rural women and their unique mental health needs, rural counselors are left with few evidence-based practices to utilize when working with this population (Imig, 2014). Historically, counseling researchers have equated “mentally healthy adults” with “mentally healthy adult males,” resulting in literature that is focused on best practices more appropriate for men (Broverman et al., 1970), and potentially upholding sex-role stereotypes within the fields of psychology, social work, medicine, and mental health counseling (APA, 2018; Schwarz, 2017). More recent researchers have demonstrated the efficacy of gender-specific counseling approaches (Enns, 2017). However, the approaches often do not consider the additional barriers to services that rural women may face, such as long distances to services, limited availability of mental health professionals, and the stigma of seeking services in a rural area (Hill et al., 2016).

In this transcendental phenomenological study, we sought to explore the lived experiences of licensed professional counselors (LPCs) who work with rural women in terms of their perceptions of rural Midwestern women’s mental health, and the academic training they received to prepare them for working with rural women. The study sought to answer the following research questions: (a) What are the lived experiences of LPCs who work with rural women?; (b) What are the challenges and benefits of working with rural women?; (c) How are mental health services perceived by those working with rural women?; and (d) What training, if any, did the participants receive that was specific to work with rural women?

Method

Qualitative research, by its very nature, validates individuals who may be disempowered (Morrow, 2007; Ponterotto, 2010). Phenomenology is a qualitative method that helps researchers describe the common meaning of participants’ lived experiences specific to a particular phenomenon (Creswell & Poth, 2018). In this study, the phenomenon was the lived experiences of LPCs who worked with rural women. Transcendental phenomenology (Moustakas, 1994) provided a framework for the study that began with epoché, a process of bracketing the researchers’ experiences and biases, and the collection of participant stories (Creswell & Poth, 2018). For this study, postpositivist elements of transcendental phenomenology (e.g., bracketing and data analysis) were utilized to reduce researcher biases (Moustakas, 1994). Specifically, we viewed bracketing as essential because participants might not share the feminist viewpoint of the researchers. The infusion of feminism into the study came from a constructivist/interpretivist standpoint as I (i.e., first author and lead researcher) believed—based on literature—the stories of rural women were not being heard and, thus, designed the study to help illuminate the experiences, mental health needs, and resiliency of rural women (Morrow, 2007).

Participants
For this study, participants were recruited using criterion and snowball sampling. Criterion sampling involved selecting individuals on the basis of their shared experiences and their abilities to articulate those experiences (Heppner et al., 2016). Snowball sampling allowed for selecting participants who previously had a demonstrated interest in this area of research based on their connection to other participants. Criteria for participation included a degree from a CACREP-accredited counseling program, licensure within their jurisdiction, current practice, and clinical work that included rural women. To recruit participants, we collected names and emails from a Midwestern state counseling association; however, this method produced only two responses. So, we utilized snowball sampling by asking participants to refer us to others who met our eligibility criteria (Creswell & Poth, 2018). We determined the number of LPCs needed to describe the phenomena by achieving saturation of the data collected (Heppner et al., 2016). This saturation was reflected by eventual redundancy in participant responses.

Following approval from the appropriate IRB, an invitation to participate was emailed to potential participants and included a link to a demographic form and informed consent for those who met the criteria and wished to participate. Rural areas were defined as those geographic areas containing counties with populations of less than 50,000, a definition that did not include population density but was appropriate for the Midwestern areas included in the study (Smalley & Warren, 2014). Twelve mental health counselors met the eligibility criteria for participation and enrolled in the study.

All participants had graduated from a CACREP-accredited counseling program, were licensed to practice within their jurisdiction, were currently practicing privately or in an agency, and had a clinical caseload that included rural women. The designation of LPC was used throughout the study and included all levels of licensure within the various jurisdictions. All of the LPCs reported working with a wide variety of mental health issues; three of the LPCs had addiction counseling credentials. Eleven participants self-identified as female and one self-identified as non-binary. Eleven participants self-identified as Caucasian, and one self-identified as Native American. Years of experience working as a mental health professional ranged from 4 years to 27 years, with an average of approximately 12 years. All participants reported working with both urban and rural clients, and one participant listed a reservation as the primary location for her work. LPCs’ clients included adult rural women from the upper Midwest. The rural women were single or married with children, working or unemployed, Caucasian or Native American. In addition, all the participants expressed a connection to rural areas, either through personal experience of growing up in a rural area or through connections with extended family. Each participant chose a pseudonym that is referred to throughout the manuscript.

Data Collection
We collected data through individual semi-structured interviews and participant artifacts. The semi-structured interview format allowed for more collaboration and interaction between interviewer and interviewee (Creswell & Poth, 2018). In this way, the interview format aligned with a feminist research approach and helped eliminate a power differential between researcher and participant (Heppner et al., 2016). There were 12 interview questions aimed at exploring participants’ work with rural women, participants’ perceptions of the unique mental health needs of rural women, the influence of participants’ rural heritage on their work with rural women, challenges and benefits of participants’ work with rural women, and participants’ training specific to work with rural women (see Appendix for all 12 interview questions). As lead researcher, I conducted all 12 interviews in order to maximize consistency in employing the interview protocol while allowing participants to elaborate on responses. Interviews ranged from 30–45 minutes. All research documents, such as informed consents, demographic questionnaires, and transcriptions, were securely stored on a password-protected device.

Participants were invited to share artifacts that represented their work with rural women. Artifacts could include personal letters, poems, artwork, and photos (Heppner et al., 2016). The artifacts in this study provided an opportunity for broader expression of the counselors’ experiences as well as understanding their connection to rural life. Seven artifacts were pictures of objects or individuals that inspired participants’ work with rural women, two were stories about experiences of rural women, and one was an original poem entitled “Rural Woman.”

Data Analysis
Brown and Gilligan’s (1992) research of young women and relationships utilized a Listener’s Guide for analyzing data. This guide is feminist and relational and allows researchers to pay attention to unheard voices. The Listening Guide is considered a psychological method that reflects the “social and cultural frameworks that affect what can and cannot be spoken or heard” (Gilligan & Eddy, 2017, p. 76). The method included three successive “listenings”—one for plot, one for “I” statements, and one for the individual in relationship to others (Brown & Gilligan, 1992). Throughout the listening process, I looked for and highlighted significant statements the participants made during the interview process that reflected the experiences of the phenomenon. I organized information via a phenomenological template under the heading “Essence of the Phenomenon” and included personal bracketing (epoché), significant statements, meaning units, and textural and structural descriptions (Creswell & Poth, 2018). Although a transcription service was utilized to transcribe the interviews, I read through the transcripts several times and coded data into categories or themes, which emerged organically from the transcripts. An independent peer reviewer then examined the transcriptions and helped to develop the codes and themes. We developed clusters of meaning from the significant statements into themes, followed by a textural and structural description that encompassed the significant statements and related themes. The rich and thick descriptions became the essence of the phenomenon enhanced by continual review of the interview tapes, journal notes, artifacts, and other data collected (Morrow, 2005).

Epoché
The epoché section was written from my perspective as the primary researcher and first author. I was responsible for designing the study, collecting and analyzing data, and writing the manuscript. My co-authors served as consultants in designing the study and helped to write and edit the manuscript. As the primary researcher, I sought to see the lived experiences of participants from a perspective that was free from my assumptions (Creswell & Poth, 2018). I grew up in a Midwestern rural area, steeped in traditional gender roles, while witnessing significant change for all women in expectations and opportunities. During the process of the study, it became apparent that my perceptions of rural women as stay-at-home farmwives have changed to reflect a population more diverse in ethnicity, family structure, and socioeconomic status; however, the traditional patriarchal expectations have not changed. My work as a mental health professional shaped my desire to explore the perceptions of other LPCs’ experiences of their work with rural women. Prior to the data analysis, I bracketed my personal and professional rural experiences about power differentials within rural areas.

Trustworthiness
To promote trustworthiness, I utilized self-reflective journaling, member checks, the achievement of data saturation, independent peer review, and an external audit. I kept a journal and made notes throughout the data collection process to facilitate an awareness of biases and/or assumptions that emerged during the process (Heppner et al., 2016; Morrow, 2005). I also conducted member checks, asking all participants to review and provide feedback via email on descriptions or themes (Creswell & Poth, 2018; Morrow, 2005). Frequently, participants would elaborate on themes by adding clarification to their responses to the interview questions. The “prolonged interaction” (Ponterotto, 2010, p. 583) with participants was significant for developing an egalitarian and unbiased relationship between researcher and participant. This strategy was congruent with feminist theory because it acknowledged the subjectivity of the researcher within the study and facilitated a collaborative relationship between researcher and participant (Morrow, 2007).

Coding the data into categories or themes helped arrange the large amount of data that was collected. The process was made easier by taking notes, or “memoing,” when reading through the information. The peer reviewer evaluated potential researcher bias by checking the coding against all transcripts, serving as a “mirror” that reflected my responses to the research process (Morrow, 2005, p. 254). Next, we discussed possible themes that emerged from the data (Heppner et al., 2016). I also utilized an external auditor to aid in establishing confirmability of the results rather than objectivity (Morrow, 2005). The auditor examined the entire process and determined whether the data supported my interpretations (Creswell & Poth, 2018). Both individuals had participated in phenomenological research and were not authors of this article.

Results

Analysis of the interview transcripts, the artifacts, and the journal reflections resulted in eight themes, organized into two categories. I further categorized each theme as: 1) textural, a subjective experience of the LPC’s experience with rural women; or 2) structural, the context of the experience. According to Moustakas (1994), the textural themes represent phenomenological reduction, a way of understanding that includes an external and internal experience; the structural themes represent imaginative variation, the context of the experience. One of the themes, counselor experience, fit the description of both textural and structural. The categories represented two distinct dimensions of the phenomenon: (a) LPCs’ perceptions of their work with rural women, and (b) LPCs’ perceptions of rural women and issues related to mental health.

Dimension 1: LPCs’ Perceptions of Their Work With Rural Women
Five textural themes emerged from the coding process; I took the names of three of these verbatim from the interviews. The textural themes included 20 codes that represented the subjective experiences of LPCs’ work with rural women. The participants’ pseudonyms were inserted into the direct quotes included in theme descriptions. Artifacts offered by participants were also included.

Bootstraps
Rooted in the familiar saying of “pull yourself up by your bootstraps,” this theme included codes of resilient, stoic, self-sufficient, and independent. According to LPCs’ perceptions of rural women, bootstraps described an acceptance of the current conditions of rural life and a reliance on past experiences for guidance. Many of the LPCs believed that rural women came to counseling with a skill set that, as Nancy said, “can teach us and others about how to be resilient.” Fave commented that working with rural women also required patience:

It’s this sense of “I can do this.” There are more demands with farming, and rural women still believe they should be able to do it all. When they come into counseling it can be difficult because they have worked hard to sort of protect this thing and keep it close to them because they’re pretty sure they can figure it out themselves.

Courtney shared a story about a ranch woman who was grieving the loss of her husband and was struggling with family issues. She remarked in one session, “Today I decided it was time to put on my red cowboy boots.” For Courtney, this represented her client’s resiliency and stoicism—“I’ve got this, and I’ve got my red boots on to prove it.”

Trailblazer
Trailblazer included pioneer, open-minded, resourceful, educated, and empowered; these words described LPCs’ perceptions of rural women’s abilities to move past accepting the realities of rural living and work toward change for improving themselves, their families, and their communities. According to the LPCs, this theme is distinct from bootstraps in that it is future-oriented rather than past-oriented. Elsie first referred to trailblazer when she told a story about a client who began recycling in the early 1980s: “She had bins and bins of recycling because she said, ‘I’m gonna leave this planet in a different shape than I found it.’ Rural women very much can be trailblazers.” The LPCs’ perceptions represented a new perspective that reflected resourceful change-makers, educated and empowered to challenge the status quo.

As one of her artifacts, Courtney offered a story about one woman’s determination to make Christmas special even though there were no resources for gifts and decorations. The woman found a large tumbleweed, covered it with lights and decorations, and declared it beautiful. Courtney said, “She was not just making do, but making things better.”

Challenges of Rural Women
LPCs observed multiple challenges for rural women including isolation, poverty/financial insecurity, role overload, grief, and generational trauma. Layla talked about the complex grief that was experienced by Native American women. She commented that “the death of a family member can mean losing someone from three or four generations. There is grief from loss of jobs, moving from the reservation, and loss of culture.” LPCs cited role overload as one of the most common experiences among rural women. Many rural women worked full-time jobs in addition to caring for family members while contributing to the farm/ranch operation. Jean observed that rural women “are responsible for everyone’s emotions in the family, sometimes leaving them isolated within the family.” LPCs believed that the isolation contributed to vulnerability. Rural women faced domestic violence, anxiety, depression, and addictions, exacerbated by having no one to talk with and long distances to services. Jean noted that resistance to change was perpetuated by the fear and control inherent in domestic abuse for many of her clients and led to complacency in reporting. The challenges of rural women described by participants defined the issues that LPCs faced when working in rural areas and increased their awareness of the critical needs of rural women.

Protective Factors
Protective factors included a sense of identity and the strong support systems of families and community that gave rural women “a lot of people that you can draw upon to help you through hard times,” according to Nancy. Her clients valued the easy access to nature and the opportunity to “immerse yourself in something bigger than yourself. It’s a way to build resilience and find meaning and joy spending time outside.” Layla found a strong sense of identity evident in rural Native women as central to the ability to teach their children cultural beliefs—a protective factor for future generations.

Nancy shared a picture of a family moving their 100-year-old home to a new location as her artifact. Her description of the house and rural heritage symbolized part of what she believed was important for rural women—the connection to family and heritage along with a sense of purpose in maintaining family culture. She said, “It’s a good way to pass down the family stories and even the family culture.”

Counselor Experience
Counselor experience (textural) included the reasons why participants chose to become LPCs. These included the motivations that sustained their work and advice for new counselors. Assumptions about diversity, a sense of purpose, listening, and connections to resources encapsulated this theme.

Layla became a counselor because she wanted “to give back to my Native people.” Nancy believed that the work with rural women helped her build a rural counselor identity. Woods’ early experience with rural women felt profound because of the chaos she observed in the lives of her clients, many of them impoverished single mothers struggling to survive. She was given a sense of purpose in her work saying, “These women are burned into my head.”

When asked about advice for new counselors who anticipate working with rural women, participants offered the following brief statements:

“Don’t make assumptions.” (Courtney)
“Ask to be taught.” (Marie)
“Hear their story without filtering through your own personal lens.” (Nancy)
“There is a difference in working in rural areas—a conservative mind-set, practicality—and you need to meet people where they are.” (Kay)
“Listen more than you talk.” (Suzie)
“Have respect for their culture.” (Layla)

LPCs’ Perceptions of Rural Women and Issues Related to Mental Health
Three structural themes represented what Moustakas (1994) termed imaginative variation, the acknowledgment of the context of multiple perspectives. The themes were derived from nine codes that provided a vital aspect of further describing the phenomenon. The theme descriptions included participants’ quotes and artifacts.

Perceptions of Rural Heritage
This theme represented LPCs’ view of rural life, including traditional values, heritage, and expectations/perfectionism. According to participants, many of the rural women embraced the traditional values of their rural heritage, and the roles of rural life; this theme honors that perspective. Fave talked about the expectations that rural women often have of themselves: “It’s a perfectionist perspective, meaning they can do it all.” Even in light of the increased demands on rural women’s time and energy, Marie found that rural women were often hesitant to seek outside professional mental health counseling, choosing instead to rely on family and community.

Barriers to Mental Health Services
The barriers included codes of lack of resources, stigma, and invisibility. All LPCs felt concerned about the lack of resources for rural women. Suzie talked about the dearth of women’s shelters on the reservation and resources for women who are victims of domestic violence. Suzie said, “They often stay because there are no resources for them to leave, and they can’t afford it.” Woods noted the lack of daycare providers and the fact that many rural women cannot afford these services and depend on family members for childcare. According to several LPCs, rural women do not prioritize their mental health needs, possibly because of the many demands on them.

Kay and Marie practiced in an urban area but saw many rural women who chose to travel long distances for mental health services because it gave them a sense of anonymity. Kay said, “They know if their car is parked at the counselor’s office, it won’t be recognized by everyone in town.” Rural women also feared exposing family secrets if they disclosed something to a counselor who lived in the same area.

Poignantly, LPCs acknowledged the invisibility and minimization of rural women’s mental health needs. The following comments by participants exemplified the rural woman’s experiences of being unnoticed or dismissed. Elsie stated, “Even if rural women are speaking, they don’t have the platform like urban women do, and they feel like nobody gets this life.” Kay stated, “Everything is fine, everything’s great and we’re not going to talk about the fact that Grandma is crying all the time and wearing sunglasses.”

The statements of the participants provided powerful examples of the ramifications of the silencing imposed on rural women through traditional or cultural norms. The stigma of accessing mental health services created a loss of connection between the rural women who needed the services and their community. In addition, rural women often felt selfish in seeking services just for themselves. The consensus among LPCs was that rural women suffer to a greater extent than other rural populations because their needs are minimized or not recognized. Elsie remarked that rural women do not often see their stories in mainstream media, leading them to believe “I’m living this experience that nobody else lives.”

The description of the artifact contributed for this theme may further elucidate the invisibility of rural women. Woods’ artifact was a picture of two locally designed sculptures of women. Woods said, “They are so rooted and earthy.” One sculpture had no arms or legs and, for Woods, that “speaks to the limited access to needed supports and the lack of voice.”

Counselor Experience
Counselor experience (structural) described how LPCs provide mental health services to rural women and included connection to rural life, distances and dual relationships, and lack of academic training/postgraduate training. Although not all the participants grew up in rural areas, many had rural ties through extended family. Marie’s upbringing on a ranch influenced her understanding of rural women: “There is a more intense work ethic; women are very strong and independent and hardworking.”

The LPCs seemed to feel a strong sense of purpose in their work; some of them chose to become counselors and returned to their home communities to work. They discovered that the connections of shared experiences fostered trust in the counseling relationship and process. Most felt that they were helping to make positive change. Although all participants believed the connection to a rural heritage was critical in their work with rural women, some LPCs did not live and work in the same location, saying it helped to reduce the possibility of multiple relationships. Nancy commuted almost an hour to her work “because you really want to have the counseling relationship be through your therapeutic lens and not through the community lens.”

None of the participants recalled receiving academic training specific to rural areas; however, all participants agreed on the need for academic training focused on rural areas and rural women. Elsie believed that textbooks should “include women’s voices and rural voices.” Jean expressed her concern that “We don’t necessarily address rural women or what they need from the communities around them or even what their typical experience is. I think that’s a disservice to our counseling students.”

Two artifacts aligned with this theme: Marie’s picture of a young girl, dressed in overalls, pitching hay, and Mae’s great-grandmother’s writing desk (see Figure 1). Marie’s artifact exemplified the family’s connection to rural life and the physical strength of rural women that she observed in her work. Mae now uses the writing desk in her practice and feels it gives her a strong connection to her rural heritage.

Figure 1

Mae’s Great-Grandmother’s Writing Desk


Note. Mae presented this picture of her great-grandma’s writing desk when asked to provide
an artifact that demonstrated her work with rural women.

 

Discussion

LPCs described rural women as strong, independent, resourceful, and resilient. However, this image of rural women was not corroborated within the research literature. An APA report on the behavioral health care needs of rural women (Mulder et al., 2000) did not mention resiliency as a coping strategy; however, in 2006, the report’s lead author recognized the need for additional research about resiliency in rural women, saying it would offer “significant potential benefit to rural women” (Mulder & Lambert, 2006, p. 15). In the present study, LPCs’ perceptions of rural women as resilient called attention to the innate strengths of rural women that developed out of necessity, cultivated by connections with family, community, and earth.

Rural heritage represented a dichotomy of rural tradition. From a positive perspective, participants believed the traditional roles of rural women provided a sense of identity and belonging. From a negative perspective, the traditional patriarchy evident in many rural areas dictated social and cultural norms, leaving rural women with the expectation that they should be able to “do it all.” Both perspectives defined a critical aspect of LPCs’ understanding of rural women. Even though many of the rural women participants described worked full-time to contribute to household income and health insurance (in addition to caretaker responsibilities), they faced gender inequities in income, employment, and educational opportunities (Watson, 2019). In addition, rural women have had little political power to effect needed policy changes for better access to care (Van Montfoort & Glasser, 2020).

LPCs highlighted multiple challenges that rural women experience: isolation, poverty, grief, role overload, and generational trauma. Barriers to obtaining services included stigma of mental health issues, loss of anonymity, a lack of resources, invisibility, and minimization of mental health issues. The general population also faces barriers of accessibility, acceptability, and availability of counseling services (Smalley & Warren, 2014); however, there were fewer references to the mental health barriers and challenges specific to rural women (Van Montfoort & Glasser, 2020). This is surprising given that the population of rural women exceeds that of any other population group in rural areas (Bennett et al., 2013). Rural women experience higher risks of depression, domestic violence, and poverty (Snell-Rood et al., 2019). The mental health services available in rural areas, often described as “loosely organized, of uneven quality, and low in resources” (Snell-Rood et al., 2019, p. 63), compound the challenges for rural women.

As evident in the themes of assumptions and diversity, rural women represent a unique population who deserve mental health services that reflect their specific needs. Rural communities and rural women are more diverse than once believed. LPCs’ observations are corroborated by research that acknowledged differences among rural women in socioeconomic status, family structure, age, sexual identity, ethnicity, education, and geographical location (Barefoot et al., 2015). In addition, there remains a misconception that the mental health needs of urban and rural women are the same; in fact, much of the literature about women and mental health is based on an urban context (Weaver & Gjesfjeld, 2014). The findings of the current study support the lack of recognition of the context of rural women’s issues and their status as an invisible population (Bender, 2016). Two LPCs’ observations of the isolation felt by rural women reinforced previous research of the invisibility of rural women. Elsie said, “Rural women don’t see their story a lot,” and Fave shared that “a lot of the women I work with don’t feel like they’re heard.”

None of the participants recalled academic training or postgraduate opportunities specific to work in rural areas or with rural women. Even though rural areas represent the largest population subgroup in the United States (Smalley & Warren, 2014), this study suggests that new counselors may not feel prepared to meet the needs of this underserved population. The shortage of mental health professionals working in rural areas and the lack of counselors who have training specific to rural mental health care suggest a need for rural-based training that might include an elective course in rural mental health and rural internships (Fifield & Oliver, 2016).

Implications

The recognition of the challenges and benefits of working with rural women may validate rural LPCs’ experiences, promote their professional identity as rural counselors, and potentially decrease the isolation felt when working in rural areas. Protective factors, including connections to family, community, and nature, may be critical for building resiliency in both rural women and rural LPCs. The increasing diversity of rural women is often contrary to the traditional stereotype of a stay-at-home farmwife (Carpenter-Song & Snell-Rood, 2017); diverse rural women may face unique barriers to accessing culturally relevant mental health services. In addition, many rural women experience role overload from working full-time and caring for families while contributing to the farm/ranch operation. Counselors should avoid interacting with rural women clients in ways that limit their identities based on stereotypes and work to make their services accessible for all women.

The study results also have implications for counselor educators. Rural-based counselors in this study did not report being taught how to work with rural women. A review of the 2016 CACREP programs found few gender-based counseling courses and none that addressed rural mental health. Programs could offer electives on counseling in rural areas, incorporate the context of gender and rural mental health into current curricula, and encourage rural internships. Collaborating with other rural health professionals may provide more informed approaches to working in rural areas. Rural residents may see their PCPs for mental health–related treatment, as PCPs may be the only health care provider in rural areas (Snell-Rood et al., 2017). Lloyd-Hazlett et al. (2020) suggested creating additional training for LPCs who choose to work in settings offering integrated care. Incorporating LPCs who have the appropriate training and skills into rural medical settings may offer mental health services in a familiar clinical context and one that does not broadcast engagement in mental health care. The collaboration may also provide more awareness of the mental health needs of rural women.

Limitations

The study has several limitations. Although I took measures to reduce any personal bias as a non-traditional rural woman, I do not believe it is possible to eliminate all biases. Many of the participants talked about empowering rural women and working toward making their clients’ voices heard, both tenets of feminist theory (Evans et al., 2005); however, participants rarely used the language of feminism. Several of the participants related personal stories of their connections with rurality and, often, their stories of rural women were from decades ago. Their stories may not have represented the current generation of rural women. Another limitation relates to the demographics of LPCs because a majority of participants self-identified as Caucasian and female and represented rural areas in the Midwest. LPCs working in other areas of the United States may encounter different demographics of rural women, mental health challenges specific to region, and unique intersections of their clients’ identities. Finally, the experiences of rural women were heard through LPCs and not from rural women clients themselves.

Directions for Future Research

This study included a sample of rural LPCs who were primarily Caucasian females from the Midwestern United States; future researchers may seek professional perspectives from participants who represent a blend of race, ethnicities, gender identities, and geographical locations. Research with rural women as participants themselves is also an important opportunity. Based on findings from this study, future researchers might also explore training needs related to work with rural women and rural populations. Studying counselor educators who teach in counseling programs based in rural areas could also offer unique insights. This may reveal information about ways educators currently infuse rural culture and work with rural women into the curriculum. Future researchers may study counselors, health care providers, and rural women in finding ways to integrate health care services in rural areas to provide better access to services and reduce the stigma often associated with mental health. Finally, additional studies about working with rural PCPs may highlight issues (e.g., intimate partner violence) that could benefit from early screening of symptoms.

Conclusion

Gilligan offers these words: “To have something to say is to be a person. But speaking depends on listening and being heard; it is an intensely relational act” (1982/1993, p. xvi). As indicated in our findings, rural women are too often invisible and unheard. This study represents a first step in amplifying the voices of rural women regarding their specific mental health needs. The experiences of the LPCs in this study have illuminated ways to connect with rural women, listen to their stories, and validate unique aspects of their cultural identities that seem to be well illustrated in one participant’s poem:

Rural Women
Resilient; stubborn; motivated
frightened; broken; courageous
Struggling; down-trodden; strong
Relentless in self-expectation
Armed with determination.
A common thread unites us
The heart gently calls, and the
soul asks only—please—listen to me.

 

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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Appendix
Twelve Interview Questions

  1. Tell me about what comes to mind when you think about working with rural women.
  2. Tell me about where you grew up and how that has influenced your work with rural women.
  3. Tell me about how you began your work with rural women.
  4. What have you learned about rural women through your work with them?
  5. What are the unique mental health needs of rural women that you have seen in your work?
  6. Tell me about some of the benefits and rewards, if any, you have experienced working with rural women.
  7. Tell me about some of the challenges, if any, you have experienced working with rural women.
  8. How have your experiences working with rural women changed you as a mental health counselor?
  9. Tell me about any academic/classroom experiences in your graduate program that involved the mental health issues of rural women (e.g., class discussions, special projects, conversations with colleagues, internship experiences).
  10. Tell me about any training experience post-graduation that have involved the mental health issues of rural women (e.g., workshops, conference presentations, webinars, conversations with colleagues).
  11. What would you like other counselors to know about working with rural women?
  12. Please describe how the artifact that you have chosen relates to your work with rural women.

 

Lisbeth A. Leagjeld, PhD, NCC, LCPC, LPC-MH, is a program liaison and faculty member at South Dakota State University – Rapid City. Phillip L. Waalkes, PhD, NCC, ACS, is an assistant professor and doctoral program coordinator at the University of Missouri – St. Louis. Maribeth F. Jorgensen, PhD, NCC, LPC, LMHC, LIMHP, is an assistant professor at Central Washington University. Correspondence may be addressed to Lisbeth A. Leagjeld, 4300 Cheyenne Blvd., Rapid City, SD 57709, Lisbeth.leagjeld@sdstate.edu.