“You Good, Bruh?”: An Exploration of Socially Constructed Barriers to Counseling for Millennial Black Men

Mar 13, 2025 | Volume 15 - Issue 1

Demetrius Cofield

In recent years, there has been a significant increase in the prevalence of mental illness among millennials. However, there is still a significantly lower rate of millennial Black men engaging in mental health counseling compared to other marginalized groups. The lack of engagement of Black men in mental health counseling has become an increasingly popular topic in scholarly literature, yet the research is still limited. This critical phenomenological study explored the influence of social constructs on millennial Black men’s decisions about seeking counseling using a multidimensional theoretical framework combining critical race theory, Black critical theory, and Black masculinity. Sixteen participants who identified as millennial Black men who reported an interest in seeking counseling were interviewed. Results indicated three themes: Black masculine fragility, racial distrust, and invisibility. Implications and future research recommendations are provided for counselors and counselor educators to improve advocacy efforts to engage and retain more millennial Black men in counseling.

Keywords: Black men, millennial, mental health counseling, Black masculinity, phenomenological

On October 4, 2016, Kid Cudi, a Black male rapper, tweeted he was being hospitalized for depression and suicidal thoughts, which led to an influx of social media dialogue about the mental health of Black men and the Twitter hashtag #YouGoodMan (Francis, 2018, 2021). The hashtag provided space for Black men to tell their stories and struggles with mental health and provide each other with support. One user stated, “Kid Cudi’s situation resonates with me because I’ve admitted myself into rehab before because of depression and suicidal ideation” (Francis, 2021, p. 450). Other users discussed their experiences with counseling and medication; another user stated, “I’ve been getting help for over a year for shit that I couldn’t tackle alone. Best decision I ever made” (Francis, 2021, p. 450). The incident received media attention because Black men rarely openly discuss their struggles with mental health. The hashtag influenced the title of this article, which I revised to a more common colloquialism among Black men. For this article, Black will be used to address Black Americans or those of African descent who were born and/or raised in the United States.

Cudi, who was 32 at the time of his tweet, is considered a millennial, a generation that has endured a recent rise in mental illness (Hoffower & Akhtar, 2020). Millennial is a socially constructed label for people born from 1981–1996 (Dimock, 2019). The prevalence of mental illness in this generation has led to an increase in awareness and mental health advocacy among them, which in turn has increased counseling engagement (Hoffower & Akhtar, 2020). However, Black millennials utilize mental health services at lower rates compared to other races, and this is especially true for millennial Black men (MBM; Kim, 2018; White-Cummings, 2017). Although the stigma continues to be addressed more with this generation, Black men are still reluctant to express their mental health struggles and seek counseling; yet the literature concerning MBM and mental health remains scarce. In a generation that is working to normalize mental health treatment, this raises concerns about the barriers MBM face when considering or seeking counseling (Kim, 2018; White-Cummings, 2017). Although many social structures have been identified as barriers to treatment seeking such as stigma, race, and masculine norms, scholars have called for specific attention to masculinity and racism (Cofield, 2023, 2024). The purpose of this critical phenomenological study is to explore the influence of social constructs on MBM’s decisions about seeking counseling.

Black Men and Counseling

Black people continue to suffer because of the anti-Black systems driving this country (American Counseling Association [ACA], 2021). Anti-Black, often used synonymously with anti-Black racism, refers to a broader antagonistic relationship between Blackness and humanity that questions the humanity of Black people and influences racial violence against them (Dumas & ross, 2016). The paradox of anti-Blackness is it can be a barrier to counseling while also being a contributing factor to mental illness in the Black community. Sellers et al. (2009) and Hoggard et al. (2019) found that racial discrimination significantly impacted the mental and physical health of Black men with no regard for factors such as age, education, and income.

Compared to White men, Black women, and men of other races, Black men utilize counseling at significantly lower rates (DeAngelis, 2021; Shannon, 2023). Black men also have a significantly higher prevalence of mental illnesses such as depression and anxiety when compared to others (Cofield, 2023). Only 26.4% of Black men with depression and anxiety seek counseling compared to 45.4% of White men (DeAngelis, 2021). Additionally, suicidal death rates among Black men are four times higher than Black women, and they are increasing at significant rates (Centers for Disease Control and Prevention [CDC], 2021; National Institute of Mental Health, 2023; Tate, 2023). In 2019, more than half of reported suicides in the United States were Black men with the majority being millennials between 25–34 years old (CDC, 2021). These numbers do not consider the many non-fatal suicide attempts not reported and show a need for more attention to these concerns, as scholars have acknowledged for over 30 years (Cadaret & Speight, 2018; Coleman-Kirumba et al., 2022; Francis, 2018, 2021; Hoggard et al., 2019; Shannon, 2023; Toler Woodward et al., 2011; Ward & Besson, 2013).

The current political climate and significant rise in publicized killings of Black men would lead one to believe Black men are in greater need of counseling; however, there is no current indication of increased utilization (Cofield, 2023). Toler Woodward et al. (2011) investigated the utilization of mental health services among Black men through a quantitative analysis of trends in the use of professional and informal supports. The authors used four categories to describe mental health help-seeking behaviors among the sampled participants: professional services only (14%), informal supports only (24%), both professional and informal supports (33%), and no help (29%). However, the authors failed to provide a clear understanding of how they were defining informal supports, with the assumption being this would entail seeking support among family, peers, and non-professional resources. Additionally, the authors noted no determination of whether those who used both forms of support did so concurrently or on separate occasions and no clarification on whether those who used only one support, or none, were having their mental health needs met. Findings suggest the importance of both professional and informal support for Black men with psychiatric disorders and confirm the lack of professional support utilization. The authors also described the need for more exploration of how racism and masculinity impact help seeking both separately and together (Toler Woodward et al., 2011).

Cadaret and Speight (2018) found that stigma was a social barrier to counseling for Black men. The authors labeled the study a gateway into understanding help-seeking attitudes while also calling for future studies to specifically address racism and masculinity as barriers to counseling. Their findings were later supported by Shannon (2023) in a study exploring the impact of stigma on Black men seeking counseling, with results also supporting previous findings from Coleman-Kirumba et al. (2022). Coleman-Kirumba et al. also found masculinity, specifically Black masculinity, influenced stigma and the socialized thinking that seeking help makes Black men weak.

The limited scholarship on the lack of counseling engagement by Black men provides evidence of a gap in current literature. This study was conducted to fill that gap and to advocate for the silent struggles of Black men while allowing their stories to help improve treatment outcomes, available resources, and treatment engagement. Though many factors have been identified, race and masculinity are two that have remained consistent (Cadaret & Speight, 2018; Cofield, 2024; Coleman-Kirumba et al., 2022; Shannon, 2023; Toler Woodward et al., 2011). A common implication in the previously discussed studies is the impact of race and masculinity and the need to further explore how these social constructs act as barriers to counseling. This study aimed to achieve that by focusing specifically on racism and masculinity as potential barriers and learning more about how these and other social constructs continue to impact and influence help-seeking behaviors among MBM. Hence this study’s framework integrated Black masculinity, critical race theory (CRT), and Black critical theory (BlackCrit), which each offer key insights into the relationship between race, masculinity, and mental health.

Theoretical Framework

Black Masculinity
     Black masculinity critiques traditional masculinity rooted in Whiteness with traits like aggression, emotional suppression, homophobia, and family patriarchy (Ferber, 2007; hooks, 2004). Images of Black men are influenced by comparisons to White men, forcing unrealistic expectations on them and leading to harmful stereotypes (Smiley & Fakunle, 2016). Society’s masculine norms dictate how Black men handle emotions (Cofield, 2023). These norms often cause Black men to internalize self-hate and conform to an image created to demonize them (Akbar, 2016), which can lead to undiagnosed mental health issues. A key concept of Black masculinity guiding this study is the expectation for Black men to be tough and hide their vulnerability, which can impact their decisions to seek counseling.

Critical Race Theory
     CRT highlights the permanence of racism in societal structures and its intersection with other identities, such as gender, sexual orientation, and class, all of which can impact mental health and the likelihood of seeking counseling (Bell, 1995; Crenshaw, 2015). This study is also guided by the tenet of counter-storytelling, which empowers minoritized races to share their lived experiences of racism. However, CRT has been critiqued for underrepresenting the Black experience, leading to the development of BlackCrit (Dumas & ross, 2016).

BlackCrit
     BlackCrit extends CRT by centering the Black experience and addressing anti-Blackness (Dumas & ross, 2016). It also addresses the tension between Blackness and neo-liberal multiculturalism, which denies that racism still exists. By focusing on how Black men internalize trauma, BlackCrit connects to the emotional and psychological impacts addressed in both Black masculinity and CRT (Cofield, 2023). Together, they highlight how societal norms around race and masculinity shape Black men’s mental health and inform their decisions to seek counseling.

Methodology

The following research questions guided the methods of this study: 1) What are the socially constructed barriers to counseling for millennial Black men? and 2) How do anti-Black racism and Black masculinity influence millennial Black men’s decisions to seek counseling? I used a qualitative approach to explore how social constructs like race and masculinity influence MBM’s decisions to seek counseling.

Engaging critical theories with phenomenology, I used a critical phenomenological approach (Guenther, 2020). Critical phenomenology is an extension of phenomenology that reflects the “quasi-transcendental social structures that make our experience of the world possible and meaningful” and seeks to “generate new and liberatory possibilities for meaningful experience and existence” (Guenther, 2020, p. 15). At its foundation, traditional phenomenology fails to consider the historical and social structures that shape the lived experiences of the participants in both empirical and quasi-transcendental ways (Guenther, 2020; Moustakas, 1994). Transcendental structures are ideas or constructs that remain constant and consistent and are meant to help understand the true nature of how the world is experienced, uninfluenced by human assumptions, prejudices, or scientific theories (Davis, 2020). Social constructs such as racism and masculinity are quasi-transcendental structures because they are not constantly operating in consistent ways across all contexts and may be experienced differently among participants. Critical phenomenology is both philosophical and political. It does not seek just to identify a problem, but “it is also a creative, generative practice of experimenting with ways of addressing what is wrong without assuming that it can simply be made ‘right,’ but still aspiring to make it less wrong, less harmful, less oppressive” (Guenther, 2021, p. 8). I used this approach to develop a detailed understanding of the participants’ experiences and how they interpret them while critically questioning societal structures that create and support these experiences (Guenther, 2020).

Positionality
     As an MBM who has grappled with depression most of my life, the signs were evident, yet my limited understanding of mental health led to a silent struggle that I endured for years. The recognition of my own depression was a pivotal moment, but the fear of appearing vulnerable and weak initially discouraged me from seeking counseling. I eventually realized the difficulties of coping on my own and began counseling. This journey of healing proved to be a decision I never regretted. Also, as a Black man and counselor, I have witnessed the troubling lack of advocacy focused on engaging more Black men in counseling. This issue is personal to me, as I feel a calling to support and uplift other Black men struggling with mental illness through my unwavering commitment to research and advocacy.

Participants
     Eligible participants needed to self-identify as MBM who have considered seeking counseling, including those who had never sought treatment. Participants needed to be 25–40 years old, following the age range of millennials at the time of the study (Dimock, 2019). Eligibility was determined through a pre-screening of demographic questions and questions regarding both interest in and experience with counseling, if applicable. These queries did not ask how many sessions the participants attended, if any. Participants also needed to identify as cisgender. Sexual orientation was not a factor in determining participant eligibility. The final sample consisted of 16 MBM with an age range of 29–34 years old located in multiple states in the United States, but most were in the Southeast (n = 9). All participants were college educated with some diversity in marital status (n = 11 single; n = 5 married) and sexual orientation (n = 12 heterosexual; n = 3 bisexual; n = 1 homosexual; n = 1 no label). Pre-screening responses indicated those who had been to counseling (n = 12) and those who had not (n = 4). Those who had engaged in counseling reported their experiences were positive (n = 8), negative (n = 2), or neutral (n = 2). Participant demographics are detailed in Table 1.

Table 1

Participant Demographics

Pseudonym Age State Sexual Orientation Marital Status Been to Counseling? Experience
Jai 33 CA No Label Single Yes Positive
Dro 31 FL Heterosexual Married Yes (couples only) Negative
Jamal 31 SC Heterosexual Single Yes Positive
Andre 34 MD Heterosexual Married Yes Positive
TJ 31 SC Heterosexual Married No N/A
Malik 29 NC Heterosexual Single Yes Positive
Micah 30 CO Heterosexual Single Yes Positive
Ali 33 PA Heterosexual Single Yes Negative
Hakeem 31 SC Homosexual Single Yes Positive
Jarrell 32 TX Heterosexual Single Yes Neutral
Tariq 30 MD Heterosexual Single No N/A
Dejerrio 32 NC Heterosexual Single No N/A
Jamarcus 33 NC Bisexual Single No N/A
Travis 32 TN Bisexual Married Yes Positive
Craig 33 MD Bisexual Single Yes Positive
Khalil 32 NC Heterosexual Married Yes Neutral

 

Recruitment and Data Collection
     After obtaining IRB approval, I used purposeful sampling for recruitment via a flyer posted by myself, colleagues, peers, and their followers who shared it on social media and in social media groups (Hays & Singh, 2012). I also used snowball sampling by reaching out to recommended participants identified by eligible participants, colleagues, or peers (Hays & Singh, 2012). Flyers included a link to informed consent and pre-screening questions. Unexpectedly, 40 eligible participants completed the screening. After ensuring eligibility, I again used purposeful sampling to select a diverse sample of 20, ensuring the inclusion of MBM who had gone to counseling and those who had not, as well as those who reported positive, neutral, and negative experiences. Email correspondence was used to schedule Zoom interviews and provide participants with potential interview questions to help prepare well-thought-out responses once they scheduled interview times. Follow-up emails were also sent out after a week if they had not responded. I did not receive any response from four of those chosen for the sample, which led to a final sample of 16 participants. I conducted semi-structured interviews, hoping that my being a Black man would provide a comfortable and safe space for participants. Interviews lasted between 45–75 minutes. Participants were asked questions regarding their beliefs toward mental health and counseling, issues they believe prevent Black men from seeking counseling, their experiences with counseling (if applicable), and how race and masculinity have impacted their beliefs about mental health and counseling. The questions were guided by the multidimensional framework and critical phenomenology. Influenced by critical phenomenology, I developed questions to illicit responses oriented “towards creative, reparative action, beyond the clarification and diagnosis of problems” (Guenther, 2021, p. 9). For this study, that meant questions that allowed participants to provide their own interpretation of race, masculinity, and what it means to be a Black man, as well as how power and history have shaped their experiences with mental health and decisions to seek counseling (Guenther, 2021). Some examples of interview questions were:

  1. What does it mean to you to live life as a Black man?
  2. How would you define “masculinity”?
  3. In what ways does your answer change, if any, when I say “Black masculinity”?
  4. How does society view Black masculinity?
  5. What would you describe as Black masculinity norms/stereotypes?
  6. Have you ever been to counseling?
  7. What factors influenced your decision to go or not go to counseling?
  8. How would you describe your experience with counseling, if you have been?
  9. What are your perceptions of the difference between counseling-seeking behaviors of Black and White men?
  10. How have Black masculine norms influenced, if they have, your decision to seek counseling?
  11. What advice would you give to Black men facing mental health challenges?
    1. Would you recommend counseling to another Black man? Why or why not?
    2. What do you believe can be done to encourage more Black men to go to counseling?

Trustworthiness
     I used multiple strategies to ensure trustworthiness and limit the effects of researcher bias. These strategies included bracketing, reflexive journals, member checking, thick descriptions, and external auditors to ensure credibility, dependability, confirmability, and transferability (Hays & Singh, 2012). Taking a critical phenomenological approach to bracketing meant suspending hegemonic norms and acknowledging my own biases and experiences with the topic to be open to different views, interpretations, and experiences while remaining mindful of how White supremacy and other forms of systemic oppression shape(d) the lived experiences of myself and the participants (Guenther, 2021). I used reflexive writing by keeping a journal to reflect on any biases that came up throughout data collection and analysis. I also had weekly meetings to reflect and debrief with a counselor educator with experience and knowledge in social justice–related research in counseling. This study was also reviewed by a committee of three counselor educators and a qualitative researcher in education as external auditors. I completed member checking by having participants review their interview transcripts for accuracy. Additionally, the significance of counter-storytelling as part of the theoretical framework and aligning with the critical phenomenological approach of this study meant centralizing the voices of the participants with the inclusion of multiple direct quotes to support the results of the study.

Data Analysis
     After interviews were completed and transcribed, transcripts were edited for accuracy and anonymity. Participants were assigned pseudonyms, though some chose their own during the interview process. Once transcripts were reviewed and edited, member checking was attempted, and participants were emailed their transcript to ensure accuracy. Some responded confirming approval while others did not. After allowing participants a week to respond, I began analyzing the transcripts. The week also gave me time to step away from the research and return with a refreshed mindset to avoid burnout and bias.

I analyzed the data using a similar modification of Moustakas’s (1994) phenomenological analysis by Eddles-Hirsch (2015) through the lens of CRT, BlackCrit, and Black masculinity. Initial analysis began while editing transcripts and journaling. Next, I analyzed each transcript while listening to the interviews, becoming more familiar with each participant’s story (Eddles-Hirsch, 2015). I completed two additional rounds of analyzing transcripts, without audio, highlighting significant statements relevant to the research questions and theoretical framework. While reviewing transcripts, I also referred to journal entries written after each interview. During the third round of analysis, the highlighted statements were recorded in a separate document. Moustakas (1994) referred to this process as horizontalization and the statements as horizons. After reviewing the list of horizons to ensure there were no repetitive, overlapping, or unrelated statements, I began grouping them based on categories developed from my review of the transcripts. This grouping process was specific to each transcript and resulted in different group labels for each participant. I then compared groups across transcripts, forming clusters of statements and modifying labels as I noticed trends and connections. This process led to what I felt was data saturation and a representation of the participants’ responses, which resulted in three themes and additional subthemes.

Findings

An analysis of interview transcripts resulted in the following three themes among all participants (N = 16): Black masculine fragility, racial distrust, and invisibility. All themes applied to both research questions, though some subthemes did not. Each theme and subtheme is described and supported with participant quotes.

Black Masculine Fragility
     Black masculine fragility is Black men’s discomfort, defensiveness, and avoidance of anything contradictory to perceptions of Black masculinity. It refers to Black men and their need to avoid feelings and emotions that threaten their masculinity and the sociocultural pressure placed on them to maintain the image. All participants reported socialized perceptions of Black masculinity when referring to reasons for not seeking treatment. The expectation that Black men are supposed to be hypermasculine, emotionless, hypersexual, heterosexual, cisgender, dangerous, providers, and protectors was fluently expressed in all participant interviews. Each participant’s explanation of life as a Black man included potential reasons MBM do not seek counseling. The following subthemes and participant quotes supported this theme.

Socialization
     Socialization (N = 16) refers to social influences on the behaviors, perceptions, values, and attitudes of Black men and their masculinity. Acknowledging masculinity as a social construct, Jai stated that it is “based upon how [society] thinks boys and men should move in, exist in, and speak within the world.” Dejerrio described the nuances of Black masculinity, stating, “You gotta have the threat of danger around you for Black masculinity. Even if you not that dangerous.” Also, in maintaining their masculinity, Black men must be hard workers that provide for and protect those they care about. Dro stated, “My idea of a [Black] man is somebody who’s able to protect and provide. Unfortunately . . . you’re not allowed to have feelings. ‘How dare you!’” Black men are conditioned to believe that no matter what they go through, the answer is always to grind harder.

Ali noted femininity, a threat to masculinity, must be avoided at all costs:

You show anything that’s not hyper strong, hyper tough, hyper emotionless, then you’re not a man. That’s feminine. . . . When Black men tend to exude things society has deemed to be feminine or Black women deem to be feminine, you really get talked about to the point where you get shamed for doing it. He can’t ask for help. His struggles must be kept secret . . . [if] you complimented me, you gay!

     TJ felt that masculinity had no place in counseling, stating, “I got to cut it off to go to therapy, but as soon as I leave therapy, I gotta cut it back on.” Comments like TJ’s shed light on MBM’s internal struggles between maintaining their masculinity and seeking help. The struggles often lead to minimizing the need for counseling, as noted by Jarrell, who after attending two sessions felt he should shoulder the burden of his own mental health because he felt there were people who needed it more than him. He provides an example of Black men glorifying the act of sacrificing their emotional well-being for others’ needs. Being socialized to think this way makes counseling seem like a foreign concept that some are not equipped to handle. Participants credited their childhoods and families for this way of thinking.

Media Influence
     Media influence (n = 15) refers to the impact of media on images of how Black men should be, the lack of portrayals of Black men in counseling, and the portrayal of them not taking it seriously when they do go. Dejerrio and Jai provided examples of TV shows from their childhood that normalized White men in counseling such as Frazier. Dejerrio stated, “The only therapy with a Black man I can think of in a movie was Bad Boys when he went to a therapist and he ends up [having sex with] her.” Jai discussed comical portrayals from TV shows like Fresh Prince of Bel Air, stating, “They went to therapy, well couples therapy . . . they started hitting each other with the balls and bats and they got into it with other people. People actually think, ‘Oh this is what therapy is, it causes more drama.’” Media portrayals can also lead to distrusting counselors. Jamarcus stated, “I would be cool to talk to you if I don’t feel like you’d be writing a blog about it. . . . I see y’all on movies and y’all be crazy. Or exploiting the person.” The media can lead to inaccurate perceptions that counselors cannot be trusted and that counseling has no benefit to Black men.

Racial Distrust
     Racial distrust refers to MBM’s refusal to see White counselors. This theme is characterized by the racial differences and lack of cultural connections in counseling and was present in all participant interviews. Jai stated, “I will not, I cannot, and I do not go to any White therapists.” Participants expressed concerns about White counselors not being able to understand their culture and experiences. Jamal stated, “The first person that I worked with was White, so I was like nah, I might just wipe off all White therapists and say they ain’t for me.” Similarly, Ali discussed his experience with a White counselor:

The environment was just not an environment that I felt was for culturally relevant healing. It was a space that I wasn’t used to. I was in this man’s home. I’m walking in and I’m like “bruh, I don’t even think you know how people like me grew up. . . . I’m trusting what you say comes from a place of understanding and not from ‘well my book told me this and I’m going to reiterate that.’ I’m Black, I’m probably not covered well in your book anyway.” I came there open, but it was just reminders to stay in your place boy, “I’m big, you’re small. I’m right, you’re wrong. White is right, and Black is wack.”

Ali’s and Jamal’s experiences point out the perceived lack of cultural competence for counseling Black men and the minimal consideration, if any, of Black people in theoretical approaches found in textbooks. Their experiences also show the impact that just one negative experience can have on discouraging MBM from continuing counseling, which Ali still has yet to do.

Invisibility
     Invisibility refers to the lack of accessibility of Black counselors, lack of knowledge about counseling, and lack of positive testimonies. The following subthemes and participant quotes illustrate this theme.

Lack of Visible Black Counselors
     Lack of visible Black counselors (n = 9) refers to MBM not knowing about Black counselors in their communities. Those who spoke about this barrier discussed how discouraging it was not seeing local Black counselors. Hakeem spoke of the impact on the image of counseling: “When I think therapy or when I think psychologist or counselor or shrink, I think of a little old White man or White lady, and I think of a couch.” Those who thought Black counselors should be more visible felt there was not enough promotion. Jamal stated, “If I’m a person living in a town and the only therapists that I’ve heard of or saw ads for are White and I’m Black, that’s probably going to dissuade me from seeking therapy.” These statements support the need for more Black counselors in the mental health profession.

Many discussed the lack of access to counseling in Black communities. TJ discussed counseling being more accessible and acceptable for White men and the likelihood that seeking help would result in seeing a White counselor. Micah stated, “Most of the people of color that I have come to learn about are booked full of the few Black or people of color that already exists here.” Micah identified how location can make it harder to find Black counselors, particularly in areas with a smaller Black population. Hakeem also discussed accessibility to mental health medication when discussing his experience with seeking antidepressants from White doctors, stating, “I have to essentially prove myself and audition for this shit . . . and it is simply because of how Black men are treated in health care.” He acknowledged the racism impacting accessibility to other forms of mental health treatment.

Lack of Positive Testimonies
     The subtheme lack of positive testimonies (n = 14) refers to the need for more MBM to share positive counseling experiences. Participants believed some MBM avoid counseling because they do not know of any Black men who have benefited from it. This subtheme is characterized by the impact of positive testimonies and how some MBM do not feel comfortable sharing their experiences. Hearing about positive experiences of Black men in counseling was influential for some participants who struggled with deciding to seek counseling. Regarding positive testimonies from his friends, Jamal stated, “Had they not had those discussions with me, I don’t know that I would have decided to go.” While Jamarcus, who has never had counseling, acknowledged the benefit of positive testimonies, the negative experiences were more significant to him. He discussed the people he knew who had gone to counseling, stating, “The majority of them, of course it helps, but I feel like there’s still a large portion as well that would say ‘I didn’t get what I really wanted from therapy.’” Still, Jamarcus’s experiences do not negate the need for more positive testimonies to outweigh the negative ones.

There are other factors that might dissuade MBM from sharing positive stories about counseling. Ali credited stigma as a deterrent to sharing, stating, “If they do, they don’t talk about it because of the stigma that exists. . . . ‘I would rather do this in quiet than you to make me feel bad or me to have to defend it.’” These statements identify another internal struggle for MBM when it comes to the stigma associated with counseling.

Lack of Clear Knowledge and Understanding
     Lack of clear knowledge and understanding (n = 15) refers to misconceptions MBM have about counseling. Many had the wrong idea about counseling or lacked knowledge of how to seek it. Malik stated, “The reason why [they] don’t go is, 1) people gonna think you crazy, 2) they think it’s expensive, and 3) they don’t know how to find one or what they should look for.” This subtheme is characterized by counseling myths and the process of getting started.

The inaccurate belief that counseling is only for severe situations was common among those who had not gone. Tariq stated, “I think most of the things that I’ve dealt with mentally and emotionally had been akin to colds and stuff like that, things I wouldn’t go see a doctor for.” The misunderstanding of why to seek counseling is one influenced by masculinity when it comes down to MBM feeling they must admit to things being bad or more severe than “a cold.” Still, there are other misunderstandings about counseling that also act as barriers.

Almost every participant who had never been to counseling stated it was too expensive. They were unaware that most health insurance plans cover counseling. Dejerrio stated, “There should be more information readily available, and the current insurance system doesn’t help anything because it’s so confusing.” Beyond the lack of understanding of insurance policies, participants highlighted the confusion that comes with finding a counselor. Tariq stated, “Not really understanding the resources plays into it. . . . I think I’m still a little bit less clear about how to secure something like that. . . . it’s not as clear to me where to go for therapy.” Tariq, Dejerrio, and other participants who did not understand the process of getting started with counseling were given a thorough explanation with suggestions and resources to assist them.

Discussion

The following research questions guided this study: 1) What are the socially constructed barriers to counseling for millennial Black men? and 2) How do anti-Black racism and Black masculinity influence millennial Black men’s decisions to seek counseling? The three themes derived from participant responses provided answers to both research questions. Additionally, the themes and subthemes are all consistent with the tenets and principles of the theoretical frameworks. In response to the first research question, the three themes provide specific insight about the perceived barriers. Black masculine fragility details how the social construction of race and masculinity influences the behaviors, perceptions, values, and attitudes of MBM and discourages them from seeking help. Racial distrust is a result of socially constructed racial identities that lead to cross-racial trust issues for MBM when deciding if they will seek counseling. Lastly, knowledge is a social construct, and the counseling profession can also be shaped by social norms and cultural values, which makes the invisibility of Black counselors, MBM who engage in counseling, and information about counseling results of social construction.

In response to the second research question, all three themes provided insight. The results of this study suggest MBM are socialized based on their race and gender, which impacts their views on help seeking. Because of anti-Black racism, MBM find it hard to trust White counselors, which creates a barrier to treatment when the common belief is that counseling is for and provided by White people. Systems of anti-Black racism impact the visibility of Black counselors, and Black masculinity discourages MBM from sharing positive counseling testimonies. Only race was evident in the lack of clear knowledge and understanding subtheme. The themes provide evidence to conclude that anti-Black racism and Black masculinity are barriers to counseling for MBM, discouraging them from seeking treatment.

The theme Black masculine fragility aligned with CRT, BlackCrit, and Black masculinity, and participants’ definitions of Black masculinity accurately aligned with the literature (Ferber, 2007; hooks, 2004). Black masculinity establishes norms for dealing with emotions; specifically, how Black men should not express emotions, thus leading to not acknowledging their mental health concerns and seeking counseling. Participants who had never been to counseling discussed not wanting to show emotions and be perceived as feminine, gay, or weak. Though not all participants agreed with this idea, they acknowledged that it was common among MBM. Dumas and ross (2016) spoke of the significance of anti-Blackness questioning the humanity of Black people. Black masculine fragility illustrates the internalized disregard of their humanity—it is anti-Black for Black men to believe their emotions do not matter, and they are only as good as the work they do to provide and protect.

Racial distrust refers to the lack of trust and comfort MBM have with engaging in counseling from White counselors and their refusal to do so. Racism plays a significant role in this lack of trust because of the historical violence against Black people. Some participants mentioned racial trauma being both a reason MBM might seek counseling as well as a barrier. Historical racism and oppression have understandably had a significant impact on the mental health of Black men (Hoggard et al., 2019; Sellars et al., 2009). Finding a safe space to process the trauma of navigating a racist society and witnessing public racial violence may seem impossible to many MBM who feel they would have no choice but to see a White counselor. The counseling profession is dominated by White counselors, so this is a significant barrier to treatment for MBM (DeAngelis, 2021).

Some participants attempted counseling with a White counselor, but none of them reported positive results. They expressed wanting a counselor with similar lived experiences who would not need cultural references explained to them. This also highlights the perceived lack of cultural competence for working with Black men among White counselors. This aligns with the CRT critique of liberal ideology and its acceptance of color blindness and dismissal of racism, and how current systems continue to minimize White privilege and remain centered in Whiteness (Haskins & Singh, 2015). It reflects the concerns that outdated counseling practices derived from theories created by and for White men are not effective (Singh et al., 2020).

Participants felt that counseling is easily accessible for White people, and the perception of access to counseling as a barrier has been noted in previous studies (Newhill & Harris, 2007; Ward & Mengesha, 2013). It is also worth noting that this barrier impacts access to mental health medication, as evident by Hakeem’s experiences with feeling the need to audition for medication from White doctors.

Invisibility also aligns with aspects of all three theories. Many participants acknowledged both the importance and lack of Black counselor representation as a reason they chose not to go to counseling or were initially reluctant to go. This theme was also reported by Black men and Black clinicians in previous research (Hackett, 2014; Ward & Besson, 2013). Black people account for less than 5% of mental health professionals, which includes more than just professional counselors (DeAngelis, 2021). In a report from The Association of Black Psychologists, they found that 11% of professional counselors identify as Black (Eutsey, 2024). Studies show that Black people in general prefer Black counselors (Ertl et al., 2019). This makes it difficult for Black counselors to meet the needs of the Black community. Another key component is the need for positive testimonies of MBM in counseling. Participants who had struggled with their decision to seek counseling stated they were more open to it after hearing about the positive experiences of Black men they knew. This relates to the impact of positive testimonies found in other studies (Francis, 2018, 2021; Ward & Mengesha, 2013). Some participants reported having or hearing about negative experiences with counseling; however, most did not speak of negative testimonies and instead spoke of the lack of positive testimonies. For those who did recall hearing about negative experiences or having them, they placed more value on the negative testimonies even if they could admit to hearing more about the positives. Additionally, the discussion of stigma related to this theme supported findings from previous studies (Cadaret & Speight, 2018; Shannon, 2023).

Implications
     The misconceptions participants reported about counseling make this one of the most important aspects of this study. MBM need to understand what counseling is, why they should seek it, and how to get started. Advocacy efforts should be revised to include accurate education about counseling resources geared toward MBM. More education should also include knowledge about affordability. It should be common knowledge that counseling is part of most medical insurance plans. Many people assume it is not because they do not relate it to medical coverage; however, psychotherapy is typically included with medical insurance plans (U.S. Department of Health and Human Services, 2023). This should be addressed the same way that other more common medical procedures are detailed when explaining policies. Knowledge about financial assistance for the uninsured, such as sliding scale fees and pro bono services offered by some counselors, should also be made available.

Another way to increase knowledge and resources is more marketing geared toward MBM. Participants reported it is often difficult to find Black counselors, especially in less diverse areas. Counselor directories such as Psychology Today and Therapy for Black Men are easily accessible and MBM need to be made aware of them. Although current advocacy efforts heavily promote awareness, increasing outreach efforts highlighting Black counselors could help encourage more MBM to seek help. This could include ads and promotional media that provide resources for finding local Black counselors. Participants also felt that Black counselors could do more to increase their visibility. Participants expressed the desire to hear more positive counseling experiences from Black men. Mental health advocates and professionals can encourage Black men to share testimonies publicly beyond their personal social networks. Social media has been a great resource for advocacy and can be used to provide more spaces for MBM to share their experiences with a wider audience, as shown by Francis (2018, 2021).

Lack of representation is a factor preventing Black men from engaging in counseling that has been consistent across literature (Cofield, 2023). As participants made clear, MBM are not likely to want to see a White counselor. An increase in marketing is a start to reaching more MBM, but the overall issue is the lack of Black counselors. This can be addressed through meaningful efforts to increase diversity in counselor education programs to recruit more Black people rather than pictures of Black people on webpages and empty promises in mission statements. Programs should target recruitment efforts to Black communities and Historically Black Colleges and Universities (HBCUs) and create scholarship and grant opportunities that fund Black students as an incentive to appeal to more Black people and increase recruitment.

These findings also provided implications for clinical practice. Participants who had seen White counselors felt they were not culturally competent. Counselors are expected to be culturally competent and should be able to provide culturally appropriate care to all clients (ACA, 2014; Ratts et al., 2016). However, it seems counselor education programs are not being as effective at teaching cultural competency as they have been charged to do. Following CRT and BlackCrit critiques of multiculturalism (Bell, 1995; Dumas & ross, 2016), multicultural counseling education should be incorporated in more than just the multicultural counseling course(s) and it needs to be restructured to include critical approaches to working with Black men and other marginalized groups (Cofield, 2023). For example, one way of improving clinical practice with MBM is using CRT and BlackCrit in counseling to promote culturally appropriate care (Cofield, 2022; Singh et al., 2020).

Limitations and Future Research
     The results of this study should be considered within the context of its limitations. The use of social media and snowball sampling risked the possibility of recruiting many participants with similar views based on established social connections. The social connection also highlights that similar education might have impacted results, with all participants having some amount of college education. Results might be different with MBM who are not college educated. Also, the age range required for participation was 25–40 years old but the sample age range was 29–34 years old with the majority being 31–33 years old. Location could also be a limitation, with 11 participants residing on the East Coast and nine residing in Southern states. Additionally, results may have been different had there been more participants who had never been to counseling.

There is still a need for more research in this area. Future research could explore generational differences in perceptions of counseling among Black men. This could potentially identify ways to improve advocacy efforts for Black men of all ages. Scholars might also consider exploring the experiences of Black men who have had counseling to identify factors that contribute to retention. I hope this study will motivate more researchers to further explore barriers to counseling for Black men as solutions are needed to help improve our mental health as we continue to navigate an anti-Black society that oppresses, traumatizes, and dehumanizes our existence.

Conclusion

The purpose of this critical phenomenological study was to explore the influence of social constructs on MBM’s decisions about seeking counseling using a theoretical framework of Black masculinity, CRT, and BlackCrit. The findings of this study identified three significant themes supported by previous research. The results of this study provide more detail into previously established barriers to counseling for MBM with a more in-depth exploration of race and masculinity. I offer suggestions to improve advocacy, practice, and education in counseling Black men from the voices of MBM who have considered or actively engaged in counseling.

 

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

 

References

Akbar, N. (2016). New visions for Black men. Mind Productions & Associates, Inc.

American Counseling Association. (2014). ACA code of ethics. https://bit.ly/acacodeofethics

American Counseling Association. (2021). Our responsibility as counselors to address trauma and grief caused by systemic racism. https://www.counseling.org/publications/media-center/article/2021/05/25/our-responsibility-as-counselors-to-address-trauma-and-grief-caused-by-systemic-racism

Bell, D. A. (1995). Who’s afraid of critical race theory? University of Illinois Law Review, 4, 893–910.

Cadaret, M. C., & Speight, S. L. (2018). An exploratory study of attitudes toward psychological help seeking among African American men. Journal of Black Psychology, 44(4), 347–370. https://doi.org/10.1177/0095798418774655

Centers for Disease Control and Prevention, National Center for Health Statistics. (2021). CDC WONDER: Multiple cause of death 1999–2020 [Data file]. https://wonder.cdc.gov/wonder/help/mcd.html

Cofield, D. (2022). “You good, bruh?” An exploration of the influence of race and masculinity on   millennial Black men’s decisions to seek mental health treatment. (Publication No. 29256850) [Doctoral dissertation, University of North Carolina at Charlotte]. ProQuest Dissertations and Theses Global.

Cofield, D. (2023). “Is it okay not to be okay?”: A critical literature review of barriers to mental health treatment for Black men. Journal of Black Studies, 54(8), 681–700. https://doi.org/10.1177/00219347231200885

Cofield, D. (2024). Examining the experienced barriers to seeking mental health treatment among metropolitan millennial Black men. Metropolitan Universities, 35(3), 129–149. https://journals.indianapolis.iu.edu/index.php/muj/article/view/27329/25691

Coleman-Kirumba, L. M., Cornish, M. A., Horton, A. J., & Alvarez, J. C. (2022). Experiences of Black men: Forms of masculinity and effects on psychological help-seeking variables. Journal of Black Psychology, 49(1), 32–57. https://doi.org/10.1177/00957984221098122

Crenshaw, K. (2015, September 24). Why intersectionality can’t wait. The Washington Post. https://www.washingtonpost.com/news/in-theory/wp/2015/09/24/why-intersectionality-cant-wait

Davis, D. H. (2020). The phenomenological method. In G. Weiss, A. V. Murphy, & G. Salamon (Eds), 50 concepts for a critical phenomenology (pp. 3–9). Northwestern University Press.

DeAngelis, T. (2021). Black men’s mental health matters. Monitor on Psychology, 52(6). https://www.apa.org/education-career/ce/black-men-mental-health.pdf

Dimock, M. (2019, January 17). Defining generations: Where Millennials end and Generation Z begins. https://www.pewresearch.org/fact-tank/2019/01/17/where-millennials-end-and-generation-z-begins

Dumas, M. J., & ross, k. m. (2016). “Be real Black for me”: Imagining BlackCrit in education. Urban Education, 51(4), 415–442. https://doi.org/10.1177/0042085916628611

Eddles-Hirsch, K. (2015). Phenomenology and educational research. International Journal of Advanced Research, 3(8), 251–260.

Ertl, M. M., Mann-Saumier, M., Martin, R. A., Graves, D. F., & Altarriba, J. (2019). The impossibility of client–therapist “match”: Implications and future directions for multicultural competency. Journal of Mental Health Counseling, 41(4), 312–326. https://doi.org/10.17744/mehc.41.4.03

Eutsey, F. (2024, July 31). Where are all the Black mental health professionals? Black Health Matters. https://blackhealthmatters.com/where-are-all-the-black-mental-health-professionals

Ferber, A. L. (2007). The construction of Black masculinity: White supremacy now and then. Journal of Sport and Social Issues, 31(1), 11–24. https://doi.org/10.1177/0193723506296829

Francis, D. B. (2018). Young Black men’s information seeking following celebrity depression disclosure: Implications for mental health communication. Journal of Health Communication, 23(7), 687–694. https://doi.org/10.1080/10810730.2018.1506837

Francis, D. B. (2021). “Twitter is really therapeutic at times”: Examination of Black men’s Twitter conversations following hip-hop artist Kid Cudi’s depression disclosure. Health Communication, 36(4), 448–456. https://doi.org/10.1080/10410236.2019.1700436

Guenther, L. (2020). Critical phenomenology. In G. Weiss, A. V. Murphy, & G. Salamon (Eds.), 50 concepts for a critical phenomenology (pp. 11–16). Northwestern University Press.

Guenther, L. (2021). Six senses of critique for critical phenomenology. Puncta, 4(2), 5–23. https://puncta.journals.villanova.edu/index.php/puncta/article/view/2813/2654

Hackett, J. R. (2014). Mental health in the African American community and the impact of historical trauma: Systematic barriers. [Master’s thesis, University of St. Thomas]. https://ir.stthomas.edu/ssw_mstrp/317

Haskins, N. H., & Singh, A. (2015). Critical race theory and counselor education pedagogy: Creating equitable training. Counselor Education and Supervision, 54(4), 288–301. https://doi.org/10.1002/ceas.12027

Hays, D. G., & Singh, A. A. (2012). Qualitative inquiry in clinical and educational settings. Guilford.

Hoffower, H., & Akhtar, A. (2020, October 10). Lonely, burned out, and depressed: The state of millennials’ mental health in 2020. Business Insider. https://www.businessinsider.com/millennials-mental-health-burnout-lonely-depressed-money-stress

Hoggard, L. S., Powell, W., Upton, R., Seaton, E., & Neblett, E. W., Jr. (2019). Racial discrimination, personal growth initiative, and African American men’s depressive symptomatology: A moderated mediation model. Cultural Diversity & Ethnic Minority Psychology, 25(4), 472–482. https://doi.org/10.1037/cdp0000264

hooks, b. (2004). We real cool: Black men and masculinity. Taylor & Francis.

Kim, E. (2018, October 4). Why millennial men don’t go to therapy. MEL. https://melmagazine.com/en-us/story/why-millennial-men-dont-go-to-therapy

Moustakas, C. (1994). Phenomenological research methods. SAGE.

National Institute of Mental Health. (2023). Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness

Newhill, C. E., & Harris, D. (2007). African American consumers’ perceptions of racial disparities in mental health services. Social Work in Public Health, 23(2–3), 107–124. https://doi.org/10.1080/19371910802151861

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

Sellers, S. L., Bonham, V., Neighbors, H. W., & Amell, J. W. (2009). Effects of racial discrimination and health behaviors on mental and physical health of middle-class African American men. Health Education & Behavior, 36(1), 31–44. https://doi.org/10.1177/1090198106293526

Shannon, J. (2023). A study of help-seeking behaviors for African American men: Implications for counselor education. Journal of Multicultural Counseling and Development, 51(3), 1–12. https://doi.org/10.1002/jmcd.12275

Singh, A. A., Appling, B., & Trepal, H. (2020). Using the multicultural and social justice counseling competencies to decolonize counseling practice: The important roles of theory, power, and action. Journal of Counseling & Development, 98(3), 261–271. https://doi.org/10.1002/jcad.12321

Smiley, C., & Fakunle, D. (2016). From “brute” to “thug”: The demonization and criminalization of unarmed Black male victims in America. Journal of Human Behavior in the Social Environment, 26(3–4), 350–366. https://doi.org/10.1080/10911359.2015.1129256

Tate, R. (2023, March 13). Researchers sound the alarm over rising Black male suicides. Defender Network. https://bit.ly/41iE9IW

Toler Woodward, A., Taylor, R. J., & Chatters, L. M. (2011). Use of professional and informal support by Black men with mental disorders. Research on Social Work Practice, 21(3), 328–336. https://doi.org/10.1177/1049731510388668

U.S. Department of Health and Human Services. (2023, April 20). Does the Affordable Care Act cover individuals with mental health problems? https://www.hhs.gov/answers/health-insurance-reform/does-the-aca-cover-individuals-with-mental-health-problems/index.html

Ward, E. C., & Besson, D. D. (2013). African American men’s beliefs about mental illness, perceptions of stigma, and help-seeking barriers. The Counseling Psychologist, 41(3), 359–391. https://doi.org/10.1177/0011000012447824

Ward, E., & Mengesha, M. (2013). Depression in African American men: A review of what we know and where we need to go from here. American Journal of Orthopsychiatry, 83(2pt3), 386–397. https://doi.org/10.1111/ajop.12015

White-Cummings, C. (2017, May 26). What Black millennials need to know now about mental health. Ourselves Black. https://ourselvesblack.com/journal/2017/5/26/what-black-millenials-need-to-know-now-about-mental-health

 

Demetrius Cofield, PhD, LCMHCS, LPCS, LCAS, CCS, is an assistant professor at The Ohio State University. Correspondence may be addressed to Demetrius Cofield, 446 PAES Bldg., 305 Annie & John Glenn Ave., Columbus, OH 43210-1124, cofield.18@osu.edu.

Counseling Emerging Adults: A Phenomenological Investigation of Professional Counselors’ Lived Experiences

Dec 5, 2024 | Volume 14 - Issue 3

Matthew L. Nice, Arsh, Rachel A. Dingfelder, Nathan D. Faris, Jean K. Albert, Michael B. Sickels

Emerging adults (18–29 years) are at a vulnerable developmental stage for mental health issues. The counseling field has been slow to adapt to the evolving landscape of the specific needs of emerging adult clients. The purpose of this qualitative study was to investigate the experiences of professional counselors who primarily counsel emerging adult clients. Using interpretative phenomenological analysis, data was collected from 11 professional counselors to produce four major themes of their experiences working with emerging adult clients: parental pressures, self-discovery, transitions, and dating and attachment. The findings from this study provide insights regarding practices and preparation for professional counselors to work with emerging adult clients.

Keywords: emerging adults, professional counselors, experiences, phenomenological, qualitative study 

Emerging adulthood (18–29 years) is a distinct human developmental stage between adolescence and adulthood. Arnett (2000) defined emerging adulthood after interviewing hundreds of young adults around the United States about their developmental experiences over several years. It is a period of life that is both theoretically and empirically different than late adolescence and early adulthood due to the psychosocial factors that young adults experience during this time in their lives (Lane, 2020). It is a time when individuals often leave their parents’ or guardians’ home, enter college or begin a career, seek romantic relationships, and begin to make decisions independently (Arnett, 2004). Emerging adults no longer experience the restrictions from their parents/guardians or teachers and they are not yet burdened with normative adult responsibilities. These freedoms allow individuals to develop qualities (e.g., self-sufficiency, new adult roles, major responsibilities) that are required during adulthood (Arnett, 2004).

As a result of this shift in human development, individuals in their twenties are marrying and starting families later, changing jobs more frequently, and pursuing higher levels of education than they were in previous decades (Arnett, 2015). Thus, the developmental factors and needs of this age group have been increasingly shifting. Although emerging adulthood is the most well-studied theory of young adult development, it is not without limitations. The most notable of these is the applicability of emerging adulthood features to young adults in all contexts. For example, the college experience offers young adults new opportunities to explore their identities and to try new things that non–college-going young adults may not experience (Mitchell & Syed, 2015). Additionally, emerging adulthood may be a Western-centric experience that young adults in other parts of the world may not experience in the same way (Hendry & Kloep, 2010).

Emerging adulthood is distinguished by its five defining features: identity exploration, sense of possibilities, self-focus, instability, and feeling in-between (Arnett, 2004, 2015). These features indicate normative developmental affordances and challenges, as well as help to define the common experiences of emerging adulthood (Nelson, 2021; Nice & Joseph, 2023). Identity exploration refers to emerging adults’ process of self-discovery in education, careers, and romantic partnerships. Sense of possibilities refers to emerging adults’ tendency to look to the future optimistically, imagining the many avenues they may take in their lives. Self-focus, not to be confused with selfishness, is the normative process in which emerging adults have the opportunity to focus on themselves without parental constraints, and before the responsibilities of marriage or parenthood. Feeling in-between is the developmental limbo between adolescence and adulthood, when emerging adults do not identify as an adolescent or an adult. Lastly, instability refers to emerging adults experiencing unstable and frequently changing life conditions, such as change in romantic partnerships, transitioning to and from college, or moving in and out of living situations (Arnett, 2015).

Experiencing these normative developmental features often results in challenges to emerging adults’ mental health (Arnett et al., 2014; Lane, 2015a; Lane et al., 2017). Navigating identity exploration and new possibilities by experimenting with anomalous life roles and experiences may lead to distress and failure (Lane, 2015b). The subjective experience of not feeling salient in adulthood but being tasked with new adult responsibilities that were not present in adolescence may cause periods of identity crisis and various psychological difficulties (Lane et al., 2017; Weiss et al., 2012). The various transitions such as entering and leaving college, starting and ending careers, or moving out of the house of a parent/guardian and moving in with roommates or living alone may contribute to instabilities and significant distress (Murphy et al., 2010; Nice & Joseph, 2023). Additionally, the salience of emerging adults’ cultural identities affects the ways in which they experience satisfaction with their lives (Nice, 2024). Although not every emerging adult will experience all of these difficulties (Buhl, 2007), many will respond with significant distress that may affect the critical juncture in mental health development that occurs during the emerging adulthood years (American Psychiatric Association [APA], 2022; Lane, 2015a). The mental health needs of emerging adults is often overlooked, as society may only see the opportunities for new growth, fun, freedom, and promise of being a young adult, and may overlook the instabilities and distress that accompany this developmental period (C. Smith et al., 2011).

Although emerging adults are some of the most vulnerable of the age groups for developing mental health issues (Cheng et al., 2015), including being particularly prone to anxiety and depression (American College Health Association, 2019), the counseling field has been slow to adapt to the evolving landscape of these individuals. Many counselors are challenged with using outdated developmental models to conceptualize their work with emerging adult clients that do not adequately address the nuances within this age group (Lane, 2015a). During high school years, school counselors are often tasked with prioritizing students for college and career readiness, but not for their upcoming transition into emerging adults (Nice et al., 2023). Given these circumstances, counselors who work with emerging adult clients are uniquely positioned to foster resilience, wellness, and navigation of various challenges during this often tumultuous stage of human development (Lane, 2015a). Understanding the experiences of professional counselors who work primarily with emerging adult clients may be necessary to assess the unique needs and support that emerging adult clients can benefit from in the counseling setting. Although other studies have examined the lived experiences of counselors working with specific clients (e.g., Wanzer et al., 2021) and other phenomena (Coll et al., 2019), no studies have examined counselors’ experiences working with emerging adults.

Given that there is little systematic research exploring how counselors experience working with emerging adult clients, qualitative research is a warranted methodological approach to understanding these social phenomena. Conceptualizing this study using the theoretical lens of emerging adulthood (Arnett, 2000, 2004, 2015) and its five features can assist in exploring the experiences of counseling emerging adults through a developmental perspective that accounts for the current circumstances of young adults. The present research addresses this by investigating the following research question: What are the perspectives and experiences of professional counselors working with emerging adult clients?

Method

The present qualitative study used interpretative phenomenological analysis (IPA) by collecting data through semi-structured interviews. The IPA approach was selected as the methodology for this study in order to reveal the experiences of counselors working with emerging adult clients because it permits an abundant level of data collection and interpretation and allows for consideration of participant accounts within a broader context/theory (Hays & Singh, 2023). During the interviews, participants were given the opportunity to discuss their experiences of working with emerging adult clients in order to give voice to their thoughts, beliefs, and attitudes surrounding these experiences.

Research Team and Reflexivity
     The research team consisted of the first author and principal investigator, Matthew L. Nice; four research assistants, Arsh, Rachel A. Dingfelder, Nathan D. Faris, and Jean K. Albert; and an external auditor, Michael B. Sickels. Nice holds a PhD in counselor education and supervision and has studied and worked with emerging adults in various settings. Albert is a doctoral student in a counselor education and supervision program who has worked with emerging adults in a clinical setting. Arsh, Dingfelder, and Faris were master’s students at the time of this study who were enrolled in a clinical mental health counseling program and who indicated interest in counseling emerging adults after graduation. Arsh and Faris identified as emerging adults. Sickels served as the external auditor and is a counselor educator who holds a PhD in counselor education and supervision and has several years of clinical experience counseling emerging adult clients. Nice pursued this study as part of a research agenda that includes emerging adulthood mental health. Arsh, Dingfelder, Faris, and Albert were research assistants who worked on this study because they had communicated interest in collaborating on this topic and as part of their paid graduate assistantships. Both prior to and throughout the study, these research assistants were trained on the qualitative research process, conducting qualitative interviews, and data analysis.

We engaged in bracketing to minimize the ways in which our experiences, expectations, or any potential biases might influence the study. We discussed our experiences in relation to being or having been an emerging adult, our roles as scholars who have researched emerging adults and clinicians who have counseled emerging adults, and our overall commitment to the counseling profession. During these discussions we identified our experiences, acknowledged any biases that we may have had, and talked about ways to bracket while conducting interviews. We kept analytic memos and personal notes during the data collection and coding process. Sickels examined our reflexivity in relation to data collection and coding to provide us with critical feedback.

Participants
     This study consisted of a purposive criteria sample of 11 professional counselors who met the following criteria: graduation from a CACREP-accredited counseling program, a minimum of 2 years of professional counseling experience post-graduation, and a full-time caseload of at least 60% or more emerging adults (ages 18–29) during their time as a professional counselor. Demographic data for each participant are displayed in Table 1. Pseudonyms are used for each counselor selected for the study to maintain confidentiality (American Counseling Association [ACA], 2014), along with their age, gender, race/ethnicity, highest counseling degree, years of experience as a counselor, and the type of work setting. We chose to require 2 years of counseling experience as inclusion criteria given that most states require no less than 2 years of experience to become a fully licensed professional counselor (e.g., Pennsylvania Department of State, 2024), which is a benchmark of demonstrating experience as a professional counselor. We chose not to require that participants hold licensure as a professional counselor, as we hoped to include college counselors in our study, many of whom may not seek licensure as a professional counselor, as many universities do not require counselors to hold licensure to work in counseling centers. We elected to require a full-time caseload of at least 60% of clients currently within the ages of 18–29 years to ensure that the experiences of the counselors working with this age group were substantial enough to provide generalizability.

Table 1
Participant Demographics

Pseudonym Age Gender Race/Ethnicity Education Total years as a professional counselor Type of practice
Judy 30 Female White MA 5 Private practice
Lorraine 31 Female White PhD 8 Private practice
Peter 48 Male White MA 10 College counseling center
Claire 40 Female White MA 16 Private practice
Christine 30 Female White MA 5 College counseling center
Patricia 48 Female White MA 20 College counseling center
Mark 32 Male White PhD 7 College counseling center
Theresa 30 Female White MA 5 Outpatient practice agency
Emily 39 Female White MA 2 College counseling center
Stephen 37 Male Asian MA 7 Community mental health
Sarah 27 Female Hispanic MA 3.5 Outpatient agency & private practice

Note. N = 11.

Procedures and Data Collection
     After we obtained university Institutional Review Board approval, participants were invited to participate through convenience sampling from agencies, private practices, and university counseling centers in the northeast region of the United States. We also searched online counselor directories for counselors who fit the criteria of our study. Upon completing interviews, we also recruited participants via snowball sampling by asking initial participants for recommendations for new potential participants to interview who also met our inclusion criteria. Given that many college counselors’ clients are almost all within the emerging adult age range, they served as valuable participants in our data collection. However, these counselors only see clients in the college context and do not see non-college emerging adult clients, an important and often forgotten population of emerging adults (Nice & Joseph, 2023). To assure the study focused on professional counselors, we limited our participants who worked in college counseling centers to account for less than half of our total participants (n = 5).

Interview questions were developed by the research team by first examining the extant counseling and young and emerging adulthood literature. Nice developed questions grounded by the literature and sent the questions to the research team for their suggestions, additions, and edits. The interview questions approved by the research team were sent to Sickels, who provided feedback for creating the final interview protocol. Prior to interviews, participants signed a consent form and completed a demographics questionnaire. Participants were also provided with a document outlining the five features of emerging adulthood (Arnett, 2004, 2015) that they were asked to review prior to the interview in order to better understand and answer the interview questions pertaining to these features. We conducted semi-structured interviews lasting approximately 60 minutes via Zoom over an 8-month span. Participants were offered a $20 electronic gift card as an incentive for participation. At the start of each interview, participants were reminded that questions pertaining to their clients only pertained to their emerging adult–aged clients, within the years of 18 to 29, and not any clients outside of that age range. Each interview consisted of eight open-ended questions (see Table 2). Participants were also asked follow-up questions for clarification. These questions were guided by Arnett’s (2000) theory of emerging adulthood, a well-studied and accepted understanding of the developmental markers and features that individuals experience during young adult development.

To understand participants’ experiences of counseling young adults during this developmental phase, we asked several questions pertaining to their experience of their clients’ developmental features of emerging adulthood (i.e., identity exploration, sense of possibilities, self-focus, instability, and feeling in-between) in counseling sessions. For consistency across participants, we asked each interview question in the same order during each interview (Creswell & Creswell, 2017). The pace of each interview was determined by the participant to allow for the development of richer data (Hays & Singh, 2023), with impromptu questions asked between established questions when elaboration was needed.

Table 2
Interview Questions

Question Number Question Content
1 What is your process for working with emerging adult clients?
1a Why do you choose to work with this population?
2 What developmental considerations do you make when working with emerging adult clients?
2a Can you provide an example or case using developmental considerations working with emerging adult clients?
3 To what extent does clients’ “identity exploration” factor into your counseling of emerging adult clients?
4 To what extent does clients’ “sense of possibilities” factor into your counseling of emerging adult clients?
5 To what extent does clients’ “feeling in-between” factor into your counseling of emerging adult clients?
6 To what extent does clients’ “instability” factor into your counseling of emerging adult clients?
7 To what extent does clients’ “self-focus” factor into your counseling of emerging adult clients?
8 When you look back on the process of counseling emerging adults, what other thoughts stand out which we have not discussed about the outcomes of counseling emerging adult clients?
8a How have those implications affected the outcome of the counseling process with emerging adult clients?
8b How did you respond to these outcomes as a counselor?

 

To enhance the trustworthiness, credibility, dependability, confirmability, and transferability of the data, we enlisted several procedures during data collection (Morrow, 2005; Prosek & Gibson, 2021). Field notes, researcher observations, and experiences pertaining to each interview were expressed and processed during research team meetings, which assisted in triangulation of data by confirming interpretations of interview data (Anney, 2015). Nice used member checking by sending each participant documents that outlined summaries of the emergent findings, quotes, themes, and data (Flynn & Korcuska, 2018). Of the 11 participants, 10 responded to member checking by confirming the accuracy of the documents to the best of their knowledge or suggesting new thoughts or ideas regarding the documents. To establish the confirmability of findings, analytic memos and a reflexivity journal were used to assist with objectivity in the interpretations during data analysis (Saldaña, 2021). Analytic memos were also kept to record thoughts around the meaning behind participants’ statements.

Nice used a reflexivity journal throughout the interviews and data analysis processes and made efforts to bracket assumptions as a professional in the counseling field (Hays & Singh, 2023). The purposive sampling method of clients based on their experiences of counseling emerging adults assisted in establishing transferability of the findings of the study (Anney, 2015). The trustworthiness and dependability of the study was assisted using an external auditor and peer briefer. Sickels served as the auditor throughout the study, reviewing interview transcripts, data collection, data analysis, themes, and overall processes, procedures, and coherence of the study (Flynn & Korcuska, 2018; Hays & Singh, 2023). Nice and Sickels met face-to-face or by phone to engage in peer-debriefing during all major points of the study, including Nice’s positionality, thoughts, emotions, and reactions to the procedures of the study.

Data Analysis
     Data was analyzed by following Pietkiewicz and Smith’s (2014) guidelines of data analysis. The process involves three stages: immersion, transformation, and connection. This process began with Nice listening to recordings of each interview to review the content as a whole and to mark any additional observations. Nice and the research team manually transcribed each interview. All transcribed interviews were reviewed by Nice concurrently with recordings to ensure accuracy of the transcripts and to create a deeper immersion into the data. During this process any new insights or observations were recorded in field notes and a reflexivity journal (Pietkiewicz & Smith, 2014). The rest of the research team also engaged in this three-stage process by reviewing each team member’s recordings and processing them in team meetings. Research team members participated in consensus coding team meetings after every two or three interviews, resulting in a total of five meetings. Prior to meetings team members all examined the materials for coding and submitted them to Nice. During meetings Nice led the discussions about each participant interview and the research team discussed how and why they arrived at specific codes. Intercoder reliability was maintained by Sickels, who examined each initial coding from all research members as well as the coding results from consensus coding meetings (Cofie et al., 2022).

Following IPA qualitative methodology, Nice and the research team reviewed and interpreted their notes regarding the transcripts in order to transform them into emergent themes using both hand coding and ATLAS.ti coding software (J. A. Smith, 2024). These initial themes were linked together by their conceptual similarities, which developed a thematic hierarchy (Pietkiewicz & Smith, 2014). Finally, Nice and the research team created a narrative account of each theme, which included direct quotes from the participants. The interpretations of these emergent themes and the overall interview content were reviewed by Nice and the research team in order to reach agreement on the final, distinct themes. Afterward, Sickels conducted an independent cross-analysis on the interview transcripts, notes, and emergent and final themes to ensure the accuracy and clarity of the final themes.

Results

     The data analysis process using IPA qualitative methods resulted in four distinct themes. These themes were identified and designated based on the meaning related with professional counselors’ experiences working with emerging adult clients. It should be noted that anxiety/stress was initially considered as a fifth theme; however, further coding and team meetings concluded that anxiety/stress is grounded within the other four themes and was not an independent distinct theme. Hence, the following four phenomenological themes emerged: parental pressures, self-discovery, transitions, and dating and attachment. The results of this interpretative phenomenological study are outlined in the following section.

Theme 1: Parental Pressures
     This theme indicates the expectations, criticisms, and imposed beliefs that emerging adult clients often process in the counseling session. Participants expressed that much of their experiences counseling emerging adult clients involved working on their clients’ relationship with their parents. Within this theme, participants expressed that their clients struggle with meeting their parents’ expectations, criticisms, standards, and imposed beliefs. Sarah shared:

A lot of people, whether they had good or bad relationships with their families, are learning how that looks now in their adulthood, like how they incorporate their family. So like creating more boundaries and what not, boundaries is a huge thing for this.

     Mark asserted: “Parents are always into the stuff [emerging adult clients] are doing and criticizing it, saying ‘no, do this or that instead.’ I think it pushes them into feeling like they are still this adolescent or kid.” Additionally, Stephen mentioned: “Clients might be going through, let’s say, gender identity. There’s this rejection of themselves from their parents when they were younger, and they struggle exploring who they want to be, because they were never fully accepted by their parents.” Participants largely expressed that although their emerging adult clients are adults, their parents still have a profound effect on them and what they bring to counseling sessions. Counselors experiencing their clients navigating their parental relationships is likely due to the individuation process (Youniss & Smollar, 1985). Individuation is an age-normative co-constructed process occurring in emerging adulthood in which young adults redefine their relationship with their parents after transitioning into emerging adulthood (Zupančič & Kavčič, 2014). This process often involves young adults’ fear of disappointing, seeking approval, and navigating parent intrusiveness (Nice & Joseph, 2023).

Theme 2: Self-Discovery
     The theme self-discovery refers to counselors’ experiences of assisting emerging adult clients in finding who they are, how they fit into society, and their exploration of being an adult. Judy expressed:

I just recognize that there’s a really great impact for folks during these [emerging adult] years to explore themselves and really get to know who they are, but in a space that feels comfortable and accepting. And, hey, however, you want to show up to session, you know that the counselor there has got your back.

     Similarly, Emily stated: “You know [emerging adult clients] are trying these identities possibilities on for size, you know, I could be this! What would that feel like? What would that be like?” Claire also had similar experiences working with emerging adult clients. She expressed:

Finding who they are is probably the biggest type of stress that I see [as a professional counselor]. What does it mean to be by myself? What does it mean to be outside of a family? What does it mean to be alone and not alone? But you know just kind of out there in the world.

     This theme likely speaks to the features of emerging adulthood, namely identity exploration and instability (Arnett, 2000, 2004). Exploring identities can be a stressful time for young adults, especially when some identities are marginalized (Pender et al., 2023). Participants expressed the importance of being a stable and safe place for clients as they explore who they are, who they want to be, and their place in society.

Theme 3: Transitions
     This theme highlights the worry and indecisiveness emerging adult clients struggle with as they transition to their new roles. Based on their experiences focusing on the transitions of emerging adult clients in therapy, participants identified and articulated the stressors and challenges to mental health experienced by clients facing frequent transitions. To this point, Theresa noted:

So there’s a lot of transitions that are happening within young adulthood that I find really helpful to not only manage within therapy, but just to help clients better understand themselves. It’s such a pivotal time to really test out the way in which they’re experiencing the world.

     Judy also experienced how transitions can be difficult with some of her emerging adult clients. She shared: “I had some [emerging adult clients] who have not had a traumatic background, but the instability and chaos of all these changes and transitions really threw them for a loop.” Christine noted some specific transitions she sees in her emerging adult clients:

There’s a lot of like hopping around with sort of short timelines, especially if they’re not living at home. Their room, their dorm, their apartment, whatever it is, is changing every year. A lot of students are transferring in or transferring to other schools. Their jobs are changing. They’re getting internships. Their classes are different every semester. And so the entire emerging adult experience is pretty much based on some level of instability with transitions . . . that plays into the work that I do, because I’m trying to give them a place that is stable and consistent, and somewhere that they can go and feel safe and comfortable.

     The frequent transitions and changes that occur in emerging adulthood often lead to instability and distress (Howard et al., 2010). Participants noted these transitions, their role in assisting clients with these transitions during emerging adulthood, and the importance of the counseling session providing clients with stability that they may not be receiving in other areas of their lives.

Theme 4: Dating and Attachment
     This theme signifies the instability of romantic relationships and learning healthy attachment styles that emerging adult clients bring to the counseling session. When discussing some of the most prevalent concerns emerging adult clients bring to counseling sessions, Lorraine indicated:

Dating is an interesting time in early adulthood. So I pay attention to that and I spend a lot of time on psychoeducation, paying attention to healthy, unhealthy attachment styles, unhealthy and healthy relationship characteristics, and what people would identify as like red flags. And then going into attachment styles and how they’re attaching to others is serving them or not serving them.

     On that note, Christine discussed a specific emerging adult client she is working with:

Someone I’m working with now is going through a breakup. She was with the same person for the past 3 years, and it recently ended. And so, a lot of the work that we’re doing now is processing who she is apart from the relationship and doing so in a way that feels safe for her.

Mark identified similar experiences working with emerging adult clients:

[Emerging adult clients say] “my dating relationships are nonexistent. So now I feel that I don’t have any worth because I know I can’t take somebody out on a date or go to the movies or whatever.” So I think that plays a huge role because it’s almost like something that clients that I work with experience. . . . like everything is just not stable.

     Dating and navigating romantic relationships in therapy has been widely researched in counseling scholarship (Feiring et al., 2018). Exploring these concepts with emerging adults in therapy may be especially crucial given that emerging adulthood is the formative stage in which individuals explore romantic relationships (Shulman & Connolly, 2013). Participants indicated that they process healthy and unhealthy attachment styles with clients as they navigate dating, which may be significant given the effects of emerging adults’ attachment styles on their overall mental health (Riva Crugnola et al., 2021).

Discussion

     Eleven professional counselors provided insight into their experiences and perceptions working with emerging adult clients in this study. Four phenomenological themes—parental pressures, self-discovery, transitions, and dating and attachment—were derived from participants’ perspectives. These findings support the available literature on the mental health needs of emerging adults (e.g., Cheng et al., 2015; Lane, 2015a) and extend this knowledge with increased direction.

The results of this study supported Arnett’s (2000, 2004, 2015) theory of emerging adulthood. Participants reported that their clients experience stress and anxiety from age-normative developmental experiences. The transitions and dating stress that emerging adults process in counseling can be linked to the emerging adulthood feature of instability (Arnett, 2004). The stress of self-discovery that is present in emerging adults’ counseling sessions is related to the emerging adulthood features of identity exploration, sense of possibilities, self-focus, and feeling in-between (Arnett, 2004). The parental pressure that counselors expressed are often prevalent when counseling emerging adults is consistent with individuation in emerging adulthood (Youniss & Smollar, 1985). Komidar and colleagues (2016) found that emerging adults often experience both a fear of disappointing their parents and feelings of parental intrusiveness in their lives while traversing the individuation process of redefining the parent–child relationship during emerging adulthood. The parental pressures that emerging adults process in counseling sessions is likely due to emerging adults individuating by establishing their own independence while sustaining a healthy level of connectedness with their parents (Nice & Joseph, 2023).

Participants’ experiences of their emerging adult clients expressing issues related to pressures from their parents stem from many contexts. These pressures came from parents exerting their expectations for their emerging adult children to choose specific education and careers and to perform well in them. Although emerging adults have newly entered adulthood and can explore their own belief systems, counselors still experienced their emerging adult clients feeling pressured to conform to the beliefs that their parents imposed on them. Emerging adult clients who were not meeting the specific expectations of their parents often expressed stress and anxiety from criticisms they received from their parents. These experiences are not to be confused with poor parenting. Mark reported that many parents are “helicopter parents” (Padilla-Walker & Nelson, 2012) who are overly involved in their emerging adult children’s lives; this increased involvement often results in their children experiencing stress and pressures.

The self-discovery that participants experienced their emerging adult clients undergoing was related to emerging adults not only determining who they are, but who they want to be. Given that individuals may not feel comfortable exploring their identities in the high school setting (Palkki & Caldwell, 2018), emerging adulthood may serve as a safer time for young adults to explore who they are. Discovering who they are is a formative task that is often met with much stress and instability (Arnett, 2004). Participants found that emerging adult clients often experience stress and anxiety about learning what they want in terms of careers, jobs, family roles, and communities.

Several participants used the word “scared” when describing how their emerging adult clients express their feelings about the many transitions they experience. Counselors noted that their emerging adult clients are facing many transitions, such as entering and leaving college, entering and leaving jobs, moving out of their parents’ home, moving in with roommates or romantic partners, and changing friend groups. With these transitions, counselors reported that their clients expressed a level of indecisiveness in knowing if they are following the correct path. Many of these transitions come with an increased level of new independence that counselors noted their clients had difficulty navigating. In line with prior research (Leipold et al., 2019), counselors expressed that promoting resilience and fostering coping methods during these transitions is beneficial to establishing consistency, safety, and security for emerging adults in counseling sessions.

Internet dating applications have led to emerging adults being more aware of the characteristics and criteria for who they want to date (Sprecher et al., 2019). Participants expressed that emerging adults often feel distress from the ending of relationships, conflicts with romantic partners, navigating who they want to date, and traversing internet dating applications. Several participants mentioned that their emerging adult clients’ self-worth was tied to their relationship status or who they are in a relationship. Participants reported that their clients’ attachment styles often lead to issues in dating. Participants noted that in their experiences, psychoeducation about healthy dating and attachment is often necessary to assist clients with these issues in the counseling session.

Implications for Counselor Practice and Training
     The findings from this study provide valuable insights regarding counselors’ clinical experiences with emerging adult clients with several practice implications. Professional counselors can benefit from understanding the roles that emerging adults’ parental pressures, self-discovery, transitions, and dating and attachment have on their mental health. Counselors can benefit from asking about these four themes during the beginning of the counseling relationship to build rapport and immediately assist emerging adult clients with common developmental issues experienced by these clients.

To assist emerging adult clients with negative feelings regarding parental pressures, counselors can offer clients the opportunity to bring their parent(s) to therapy. Marriage and family counselors can also intentionally address and process parental pressures in applicable family systems. Attending to emerging adult clients’ issues surrounding self-discovery has potential implications for multicultural and social justice counseling (Ratts et al., 2016). For example, emerging adult clients who identify as gender diverse or as a sexual minority may be discovering themselves in new ways that can elicit transprejudice, discrimination, and stigmatization in society (Wanzer et al., 2021). Utilizing the Multicultural and Social Justice Counseling Competencies (MSJCCs; Ratts et al., 2016) in the counseling session provides a framework for emerging adults who are discovering and exploring their cultural identities (Nice, 2024). Counselors can use the MSJCCs to understand emerging adults’ specific intersections of their identities (e.g., race/ethnicity, sexual identity, gender identity, spirituality).

Counselors can assist clients with feelings of distress regarding self-discovery, identity, and fitting in by normalizing these developmental experiences and processing their values and life desires. Regarding transitions, counselors should be intentional to assure that the counseling session is a safe and stable environment for emerging adult clients. Given the stress and instability during emerging adulthood from frequently changing contexts in college, jobs, families, friends, romantic partnerships, and living situations, assuring that the counseling session remains stable and safe can provide clients with a sense of ease and security that they may be lacking in other areas of their lives.

Addressing dating and attachment in emerging adulthood can prove to be a difficult task, as some emerging adults may be seeking monogamous relationships while others may be more interested in hooking up or casual, no-strings-attached sexual encounters that are increasingly common during emerging adulthood (Stinson, 2010). Meeting clients where they are in terms of dating can be beneficial to supporting them in their specific needs. Given the relationship between dating and self-worth (Park et al., 2011), counselors may benefit from counseling modalities such as cognitive behavioral therapy to assist clients with cognitive distortions and feelings surrounding dating and their worth. Regarding attachment, counselors can consider using attachment theory (Bowlby, 1969) with emerging adult clients struggling with their attachment types in romantic relationships.

Lastly, findings demonstrated that counselors encounter unique developmental issues when counseling emerging adult clients. It may be beneficial for counselors to be instructed on these unique needs of emerging adult clients during their counselor education programs, given the vulnerability of this age group to mental health difficulties, and the needs that participants reported (Cheng et al., 2015). Counselor educators can implement case studies surrounding emerging adult clients struggling with parental pressures, self-discovery, transitions, and dating and attachment to prepare them for real-world scenarios that they are likely to encounter while working with this population. Information on Erikson’s (1968) stages of development, specifically aspects of identity achievement versus role confusion, can align with instruction on emerging adulthood. Counselor educators should also acknowledge that the majority of counselors-in-training may be within the emerging adulthood age range and consider developmental implications for these students during instruction and mentorship (Nice & Branthoover, 2024). The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2023) standards highlight lifespan development as a foundational counseling curriculum, with lifespan development standards addressing: “1. theories of individual and family development across the lifespan” and “7. models of resilience, optimal development, and wellness in individuals and families across the lifespan.” Counselor education should include training on the unique developmental needs and issues of emerging adulthood such as the themes found within this study in order to assist in meeting these standards.

Limitations and Future Research
     Given the subjective nature of qualitative research, we implemented multiple measures of trustworthiness to account for our influence and positionality on this study. Regardless, our influence should still be considered a limitation of this study (Hays et al., 2016). Although we limited the total number of professional counselors working in college counseling centers to less than half of the total sample (n = 5), those participants only experienced emerging adults within the college context and could not speak to experiences of counseling emerging adults who have never attended college, an understudied population of young adults (Seiffge-Krenke et al., 2013). The semi-structured interviews were grounded in emerging adulthood theory and asked specifically about the five features of emerging adulthood. These questions may have influenced participants’ thoughts and feelings about their experiences with this population and affected the overall findings of the study. Finally, some members of our research team were master’s students who did not have doctoral-level research design and qualitative research classes or training. To combat this limitation, several steps were taken to assure the research team members were appropriately trained for their participation in this study, such as online trainings, training from Nice, reflexivity journals, and numerous research team meetings between interviews.

The findings from the present study suggest future investigation concerning the practices for counseling emerging adults is warranted. Whereas this study provides a distinct contribution to the professional counseling and emerging adulthood literature, studies can use these findings to explore future methods for counseling emerging adults. Given that the present study is a phenomenological examination of counselors’ experiences of counseling emerging adults, future studies should use a grounded theory methodology to generate the best practices for working with emerging adults in therapy. Interviews from both professional counselors and emerging adults currently in counseling would assist in providing a complete perspective of the needs for emerging adults in therapy.

Quantitatively, the four themes from this study can be examined in relation to stress, anxiety, wellness, and life satisfaction in order to understand the levels of distress these factors have on the mental health of emerging adults. For example, survey research seeking to understand emerging adults’ levels of stress and wellness can include the Revised Dyadic Adjustment Scale (Busby et al., 1995) and the Short Version of the Individuation Test for Emerging Adults (Komidar et al., 2016) to examine dating and attachment (i.e., Theme 4) and parental relationships and pressures (i.e., Theme 1) in relation to stress and wellness scales.

Conclusion

Counseling with emerging adult clients presents professional counselors with a unique task that includes important developmental implications to address. Consistent with emerging adulthood theory (Arnett, 2000, 2004), counselors experienced their emerging adult clients demonstrating high levels of stress and anxiety from developmental phenomena exclusive to this age range. Specifically, counselors experienced their emerging adults consistently bringing issues to counseling sessions related to parental pressures, self-discovery, transitions, and dating and attachment. Applying these insights derived from professional counselors’ experiences of counseling emerging adult clients in clinical settings and counselor education training programs can support counselors to better serve the specific needs of this frequently served population and, consequently, better address the mental health of emerging adults in therapy.

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

References

American College Health Association. (2019). National college health assessment II reference group executive summary Spring 2019.

American Counseling Association. (2014). ACA code of ethics. https://bit.ly/acacodeofethics

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Anney, V. N. (2015). Ensuring the quality of the findings of qualitative research: Looking at trustworthiness criteria. Journal of Emerging Trends in Educational Research and Policy Studies, 5(2), 272–281. https://bit.ly/Anney_truthworthiness

Arnett, J. J. (2000). Emerging adulthood: A theory of development from the late teens through  the twenties. American Psychologist, 55(5), 469–480. https://doi.org/10.1037/0003-066X.55.5.469

Arnett, J. J. (2004). Emerging adulthood: The winding road from the late teens through the twenties (1st ed.). Oxford University Press.

Arnett, J. J. (2015). Emerging adulthood: The winding road from the late teens through the twenties (2nd ed.). Oxford University Press.

Arnett, J. J., Žukauskienė, R., & Sugimura, K. (2014). The new life stage of emerging adulthood at ages 18–29 years: Implications for mental health. The Lancet Psychiatry, 1(7), 569–576. https://doi.org/10.1016/S2215-0366(14)00080-7

Bowlby, J. (1969). Attachment and loss, Vol. 1: Attachment. Random House.

Buhl, H. M. (2007). Well-being and the child-parent relationship at the transition from university to work life. Journal of Adolescent Research, 22(5), 550–571. https://doi.org/10.1177/0743558407305415

Busby, D. M., Christensen, C., Crane, D. R., & Larson, J. H. (1995). A revision of the Dyadic Adjustment Scale for use with distressed and nondistressed couples: Construct hierarchy and multidimensional scales. Journal of Marital and Family Therapy, 21(3), 289–308. https://doi.org/10.1111/j.1752-0606.1995.tb00163.x

Cheng, H.-L., McDermott, R. C., & Lopez, F. G. (2015). Mental health, self-stigma, and help-seeking intentions among emerging adults: An attachment perspective. The Counseling Psychologist, 43(3), 463–487. https://doi.org/10.1177/0011000014568203

Cofie, N., Braund, H., & Dalgarno, N. (2022). Eight ways to get a grip on intercoder reliability using qualitative-based measures. Canadian Medical Education Journal, 13(2), 73–76. https://doi.org/10.36834/cmej.72504

Coll, D. M., Johnson, C. F., Williams, C. U., & Halloran, M. J. (2019). Defining moment experiences of professional counselors: A phenomenological investigation. The Professional Counselor, 9(2), 142–155. https://doi.org/10.15241/dmc.9.2.142

Council for the Accreditation of Counseling and Related Educational Programs. (2023). 2024 CACREP standards. https://www.cacrep.org/for-programs/2024-cacrep-standards

Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). SAGE.

Erikson, E. H. (1968). Identity: Youth and crisis. W. W. Norton.

Feiring, C., Simon, V. A., & Markus, J. (2018). Narratives about specific romantic conflicts: Gender and associations with conflict beliefs and strategies. Journal of Counseling & Development, 96(3), 254–266. https://doi.org/10.1002/jcad.12200

Flynn, S. V., & Korcuska, J. S. (2018). Credible phenomenological research: A mixed-methods study. Counselor Education and Supervision, 57(1), 34–50. https://doi.org/10.1002/ceas.12092

Hays, D. G., & Singh, A. A. (2023). Qualitative research in education and social sciences (2nd ed.). Cognella Academic Publishing.

Hays, D. G., Wood, C., Dahl, H., & Kirk-Jenkins, A. (2016). Methodological rigor in Journal of Counseling & Development qualitative research articles: A 15-year review. Journal of Counseling & Development, 94(2), 172–183. https://doi.org/10.1002/jcad.12074

Hendry, L. B., & Kloep, M. (2010). How universal is emerging adulthood? An empirical example. Journal of Youth Studies, 13(2), 169–179. https://doi.org/10.1080/13676260903295067

Howard, A. L., Galambos, N. L., & Krahn, H. J. (2010). Paths to success in young adulthood from mental health and life transitions in emerging adulthood. International Journal of Behavioral Development, 34(6), 538–546. https://doi.org/10.1177/0165025410365803

Komidar, L., Zupančič, M., Puklek Levpušček, M., & Bjornsen, C. A. (2016). Development of the Short Version of the Individuation Test for Emerging Adults (ITEA–S) and its measurement invariance across Slovene and U.S. emerging adults. Journal of Personality Assessment, 98(6), 626–639.
https://doi.org/10.1080/00223891.2016.1171231

Lane, J. A. (2015a). Counseling emerging adults in transition: Practical applications of attachment and social support research. The Professional Counselor, 5(1), 30–42. https://doi.org/10.15241/jal.5.1.30

Lane, J. A. (2015b). The imposter phenomenon among emerging adults transitioning into professional life: Developing a grounded theory. Adultspan Journal, 14(2), 114–128. https://doi.org/10.1002/adsp.12009

Lane, J. A. (2020). Attachment, ego resilience, emerging adulthood, social resources, and well-being among traditional-aged college students. The Professional Counselor, 10(2), 157–169. https://doi.org/10.15241/jal.10.2.157

Lane, J. A., Leibert, T. W., & Goka-Dubose, E. (2017). The impact of life transition on emerging adult attachment, social support, and well-being: A multiple-group comparison. Journal of Counseling & Development, 95(4), 378–388. https://doi.org/10.1002/jcad.12153

Leipold, B., Munz, M., & Michéle-Malkowsky, A. (2019). Coping and resilience in the transition to adulthood. Emerging Adulthood, 7(1), 12–20. https://doi.org/10.1177/2167696817752950

Mitchell, L. L., & Syed, M. (2015). Does college matter for emerging adulthood? Comparing developmental trajectories of educational groups. Journal of Youth and Adolescence, 44(1), 2012–2027. https://doi.org/10.1007/s10964-015-0330-0

Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology, 52(2), 250–260. https://doi.org/10.1037/0022-0167.52.2.250

Murphy, K. A., Blustein, D. L., Bohlig, A. J., & Platt, M. G. (2010). The college-to-career transition: An exploration of emerging adulthood. Journal of Counseling & Development, 88(2), 174–181. https://doi.org/10.1002/j.1556-6678.2010.tb00006.x

Nelson, L. J. (2021). The theory of emerging adulthood 20 years later: A look at where it has taken us, what we know now, and where we need to go. Emerging Adulthood, 9(3), 179–188. https://doi.org/10.1177/2167696820950884286

Nice, M. L. (2024). Exploring the relationships and differences of cultural identity salience, life satisfaction, and cultural demographics among emerging adults. Adultspan Journal, 23(1), 1–13. https://doi.org/10.33470/2161-0029.1158

Nice, M. L., & Branthoover, H. (2024). Wellness and the features of emerging adulthood as predictors of counseling leadership behaviors among counselors-in-training. Journal of Counselor Leadership and Advocacy, 1–13. https://doi.org/10.1080/2326716X.2024.2361092

Nice, M. L., & Joseph, M. (2023). The features of emerging adulthood and individuation: Relations and differences by college-going status, age, and living situation. Emerging Adulthood, 11(2), 271–287. https://doi.org/10.1177/21676968221116545

Nice, M. L., Potter, P., & Hecht, C. L. (2023). The role of school counselors in preparing students for the developmental transition from adolescence to emerging adulthood. Journal of Child and Adolescent Counseling, 9(3), 260–272. https://doi.org/10.1080/23727810.2023.2183798

Padilla-Walker, L. M., & Nelson, L. J. (2012). Black hawk down?: Establishing helicopter parenting as a distinct construct from other forms of parental control during emerging adulthood. Journal of Adolescence, 35(5), 1177–1190. https://doi.org/10.1016/j.adolescence.2012.03.007

Palkki, J., & Caldwell, P. (2018). “We are often invisible”: A survey on safe space for LGBTQ students in secondary school choral programs. Research Studies in Music Education, 40(1), 28–49. https://doi.org/10.1177/1321103X17734973

Park, L. E., Sanchez, D. T., & Brynildsen, K. (2011). Maladaptive responses to relationship dissolution: The role of relationship contingent self-worth. Journal of Applied Social Psychology, 41(7), 1749–1773. https://doi.org/10.1111/j.1559-1816.2011.00769.x

Pender, K. N., Hope, E. C., & Sondel, B. (2023). Reclaiming “Mydentity”: Counterstorytelling to challenge injustice for racially and economically marginalized emerging adults. Journal of Community & Applied Social Psychology, 33(2), 300–312. https://doi.org/10.1002/casp.2662

Pennsylvania Department of State. (2024). Social workers, marriage and family therapists and professional counselors licensure guide. https://www.pa.gov/en/agencies/dos/resources/professional-licensing-resources/licensure-processing-guides-and-timelines/social-workers-guide.html

Pietkiewicz, I., & Smith, J. A. (2014). A practical guide to using interpretative phenomenological analysis in qualitative research psychology. Psychological Journal, 20(1), 7–14.

Prosek, E. A., & Gibson, D. M. (2021). Promoting rigorous research by examining lived experiences: A review of four qualitative traditions. Journal of Counseling & Development, 99(2), 167–177. https://doi.org/10.1002/jcad.12364

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

Riva Crugnola, C., Bottini, M., Madeddu, F., Preti, E., & Ierardi, E. (2021). Psychological distress and attachment styles in emerging adult students attending and not attending a university counselling service. Health Psychology Open, 8(1). https://doi.org/10.1177/20551029211016120

Saldaña, J. (2021). The coding manual for qualitative researchers (4th ed.). SAGE.

Seiffge-Krenke, I., Persike, M., & Luyckx, K. (2013). Factors contributing to different agency in work and study: A view on the “forgotten half”. Emerging Adulthood, 1(4), 283–292. https://doi.org/10.1177/2167696813487337

Shulman, S., & Connolly, J. (2013). The challenge of romantic relationships in emerging adulthood: Reconceptualization of the field. Emerging Adulthood, 1(1), 27–39. https://doi.org/10.1177/2167696812467330

Smith, C., Christoffersen, K., Davidson, H., & Herzog, P. S. (2011). Lost in transition: The dark side of emerging adulthood. Oxford University Press.

Smith, J. A. (2024). Qualitative psychology: A practical guide to research methods (4th ed.). SAGE.

Sprecher, S., Econie, A., & Treger, S. (2019). Mate preferences in emerging adulthood and beyond: Age variations in mate preferences and beliefs about change in mate preferences. Journal of Social and Personal Relationships, 36(10), 3139–3158. https://doi.org/10.1177/0265407518816880

Stinson, R. D. (2010). Hooking up in young adulthood: A review of factors influencing the sexual behavior of college students. Journal of College Student Psychotherapy, 24(2), 98–115. https://doi.org/10.1080/87568220903558596

Wanzer, V. M., Gray, G. M., & Bridges, C. W. (2021). Lived experiences of professional counselors with gender diverse clients. Journal of LGBTQ Issues in Counseling, 15(2), 240–262. https://doi.org/10.1080/15538605.2021.1914274

Weiss, D., Freund, A. M., & Wiese, B. S. (2012). Mastering developmental transitions in young and middle adulthood: The interplay of openness to experience and traditional gender ideology on women’s self-efficacy and subjective well-being. Developmental Psychology, 48(6), 1774–1784. https://doi.org/10.1037/a0028893

Youniss, J., & Smollar, J. (1985). Adolescent relations with mothers, fathers, and friends. The University of Chicago Press.

Zupančič, M., & Kavčič, T. (2014). Student personality traits predicting individuation in relation to mothers and fathers. Journal of Adolescence, 37(5), 715–726. https://doi.org/10.1016/j.adolescence.2013.12.005

Matthew L. Nice, PhD, is an assistant professor at Indiana University of Pennsylvania. Arsh, MA, is a doctoral student at Indiana University of Pennsylvania. Rachel A. Dingfelder, MA, is a professional counselor and a graduate of the clinical mental health counseling program at Indiana University of Pennsylvania. Nathan D. Faris, MA, is a professional counselor and a graduate of the clinical mental health counseling program at Indiana University of Pennsylvania. Jean K. Albert, MA, is a doctoral student at Indiana University of Pennsylvania. Michael B. Sickels, PhD, is a clinical assistant professor at Duquesne University. Correspondence may be addressed to Matthew L. Nice, 400 Penn Center Boulevard, Building 4, Suite 900, Indiana University of Pennsylvania Pittsburgh East, Pittsburgh, PA 15235, Mnice@iup.edu.

A Phenomenological Exploration of Counselors’ Experiences in Personal Therapy

Sep 13, 2024 | Volume 14 - Issue 2

Dax Bevly, Elizabeth A. Prosek

Professional counselors may choose to increase self-awareness and/or engage in self-care through the use of personal therapy. Some counselors may feel reluctant to pursue personal therapy due to stigma related to their professional identity. To date, researchers have paid limited attention to the unique concerns of counselors in personal therapy. The purpose of this descriptive phenomenological study was to explore counselors’ experiences and decision-making in seeking personal therapy. Participants included 13 licensed professional counselors who had attended personal therapy with a licensed mental health professional within the previous 3 years. We identified six emergent themes through adapted classic phenomenological analysis: presenting concerns, therapist attributes, intrapersonal growth, interpersonal growth, therapeutic factors, and challenges. Findings inform mental health professionals and the field about the personal and professional needs of counselors. Limitations and future research directions are discussed.

Keywords: professional counselors, self-awareness, self-care, personal therapy, phenomenological

Self-awareness is a fundamental part of the counseling profession. Not only do professional counselors seek to increase the self-awareness and personal growth of their clients, but counselor educators call upon counselor trainees to increase their own self-awareness before entering the field (Council for the Accreditation of Counseling and Related Educational Programs [CACREP], 2023, Section 3A11). Additionally, counselor educators often recommend self-growth experiences such as personal counseling to increase counselor trainees’ self-awareness in preparation for professional practice (Remley & Herlihy, 2020). Several scholars define counselor self-awareness as the mindfulness of thoughts, feelings, and behaviors in the self and in the counseling relationship (Fulton & Cashwell, 2015; Merriman, 2015; Rosin, 2015). Pompeo and Levitt (2014) asserted that self-awareness parallels awareness of personal values and enables counselors to explore best practices in counseling. However, after training, it becomes less clear how, if at all, counselors access their own counseling for self-growth and self-awareness; therefore, we designed the current study to explore how practicing counselors utilize personal therapy.

Correlates of Self-Awareness Among Counselors
     Counselor self-awareness relates to awareness of the counseling relationship, which is helpful to client satisfaction and growth (Pompeo & Levitt, 2014); as such, several researchers have examined the clinical implications of counselor self-awareness, including professional competence, client treatment outcomes, and wellness. For example, Rake and Paley (2009) found that the therapists in their study reported modeling themselves after their own therapist as well as learning about technical aspects of a therapeutic approach. In regard to wellness, Gleason and Hays (2019) found that counselor self-awareness helped identify stressors and needs regarding personal wellness in doctoral-level counselor trainees. Similarly, Merriman (2015) discussed how self-awareness can help prevent burnout or compassion fatigue. Many researchers have investigated the importance of self-awareness as a characteristic of counselors who can competently work with culturally diverse clients (Ivers et al., 2016; Sue et al., 2022). Thus, some evidence of the clinical impact of counselor self-awareness already exists in the literature.

Expanding upon the impacts of self-awareness on the therapeutic relationship, Anderson and Levitt (2015) articulated the importance of self-awareness in how counselors’ social influence impacts the working alliance. Additionally, Tufekcioglu and Muran (2015) described how the working alliance provides a laboratory wherein the client can focus on and more clearly delineate their experience in relation to the therapist’s experience. Thus, the counseling goal of cultivating mindfulness in clients with respect to the details of their own experience involves counselors becoming mindful of the corresponding details of their own experience. Tufekcioglu and Muran argued that every encounter with a client demands the counselor’s self-reflection in the form of greater self-awareness in relation to the working alliance, and maintained that the therapeutic process should involve change for both participants.

Counselors Seeking Mental Health Care
     Counselors can gain self-awareness in a variety of ways, including personal therapy. Mearns and Cooper (2017) stated that the term therapy loosely signifies the receiving of mental health services from any mental health professional who holds a license to practice. We use the word therapist in reference to researchers who did not specify the type of mental health professional (e.g., counselor, psychologist, social worker) who provided therapy to the participants in their study. Several scholars have suggested that therapists who participated in their own personal therapy experienced increased professional development as well as positive client outcomes. For example, VanderWal (2015) found that clients of counselor trainees with personal therapy experience demonstrated reduced rates of distress more quickly than clients of counselor trainees without personal therapy experience. Other researchers have noted the impact of therapy on therapists’ personal growth. Although not specific to professional counselors, Moe and Thimm (2021) conducted a systematic review of the literature regarding mental health professionals’ experiences in personal therapy and discovered benefits related to genuineness, empathy, and creation of a working alliance. Outcomes of this previous research support the positive impact of personal therapy for therapists.

Some counselors may seek personal therapy due to mental health concerns. Therefore, it is worth exploring the needs of this unique population. In one study, Orlinsky (2013) reported that therapists’ most frequently cited presenting concerns were resolving personal problems. Additionally, Moore et al. (2020) reported that counselors experienced interpersonal stress as a response to threatening situations in their clinical work and, in order to cope, neglected their own personal needs. Other investigators found a relationship between higher rates of ethical dilemmas in clinical practice and increased stress and burnout among counselors (Mullen et al., 2017). Robino (2019) introduced the concept of global compassion fatigue, a phenomenon wherein counselors experience “extreme preoccupation and tension as a result of concern for those affected by global events without direct exposure to their traumas through clinical intervention” (p. 274). In this conceptual piece, Robino summarized the literature findings on how indirect exposure of distressing events impact the mental well-being of professional helpers and advocated for the role of self-awareness as an important coping skill. Furthermore, Prosek et al. (2013) found that counselor trainees presented with elevated levels of anxiety and depression, providing further evidence that counselors are at risk for mental health concerns related to occupational and personal stressors.

Purpose of the Study
     The psychological needs of counselors coupled with the emphasis on gaining self-awareness highlight the necessity for counselors’ personal therapy. Self-awareness is an important component of counselor development due to the personal nature of the profession (Pompeo & Levitt, 2014; Remley & Herlihy, 2020). Personal therapy is one way to enhance counselor self-awareness (Mearns & Cooper, 2017). Additionally, counselors may experience a variety of mental health concerns, including compassion fatigue, interpersonal conflict, depression, and anxiety (Moore et al., 2020; Mullen et al., 2017; Orlinsky, 2013; Prosek et al., 2013; Robino, 2019). Researchers have primarily focused on the perceived outcomes of personal therapy, including personal growth, professional development, and positive client outcomes (Moe & Thimm, 2021; VanderWal, 2015). However, scarce research exists regarding counselors’ decision-making processes in seeking personal therapy. Thus, if counselors could benefit from personal therapy, and if little knowledge exists regarding how counselors decide to seek personal therapy, professional counselors, counselor educators, counselor supervisors, and other mental health providers have limited information regarding how to facilitate that decision-making process.

Researchers employing qualitative investigation typically seek to holistically understand meaning. More specifically, the goal of a phenomenological approach is to capture the experiences and meaning-making from the participants’ perspectives (Creswell & Creswell, 2017). We want to illuminate how professional counselors make meaning of their experiences in personal therapy, as much of the existing literature focuses on trainees, clinical outcomes, or quantitative data. We believe describing the lived experiences, or essence (Moustakas, 1994), of counselors receiving personal therapy may lead to a deeper body of research regarding the perceptions, emotions, and behaviors of this population. The following questions guided our inquiry:

  1. What contributes to counselors’ decisions to seek personal therapy?
  2. How do professional counselors make meaning of their experiences in utilizing
    personal therapy?

Method

Phenomenologists seek to understand the distinctive characteristics of human behavior and first-person experience (Hays & Singh, 2023). Based on an existentialist research paradigm, we wanted to understand how counselors make meaning of their experiences in personal therapy. Because we aimed to describe the lived experiences of counselors receiving personal therapy, descriptive phenomenology answers the research questions appropriately (Prosek & Gibson, 2021). Consistent with descriptive phenomenology, we used Miles et al.’s (2019) adaptation of classic data analysis, an inductive–deductive approach.

Research Team and Reflexivity
     At the time of data collection (pre–COVID pandemic), Dax Bevly, who identifies as a White, Latina cisgender woman in her late 20s, was completing a doctoral degree in counseling. Elizabeth A. Prosek, who identifies as a White, cisgender woman, brought experience in conducting, teaching, and mentoring qualitative research studies. Bevly utilized a research team for data analysis that included four women in their early 20s completing master’s degrees in counseling; three identified as White and one identified as Asian. As instruments in the research themselves, the team needed to embrace their potential influence and impact (Hays & Singh, 2023); therefore, Bevly and Prosek participated in research reflexivity meetings several times during data collection and analysis, where they discussed thoughts and emotions evoked through their participation in the study. Descriptive phenomenology requires researchers to establish epoche, an exchange of assumptions that can be held accountable to bracket or identify throughout the process. Our research team demonstrated epoche by journaling and discussing biases and assumptions regarding the present study throughout the data analysis process. Bevly in particular was especially aware of her own personal biases due to long-term participation in personal therapy, believing it to have highly influenced her personal and professional development in a positive way. Bevly consulted with the research team as we examined experiences, reactions, and any assumptions or biases that could interfere with the coding process during data analysis. The research team members held Bevly accountable for her responses to the research process (Creswell & Creswell, 2017). The four other members of the research team also engaged in the examination of their experiences, reactions, and assumptions or biases during analysis, reporting assumed benefits including increased awareness, higher functioning in relationships, and increased self-esteem. Bevly also utilized the research team for the purpose of engaging in critical discussion during the analysis process in order to develop a trustworthy study. Furthermore, Bevly and Prosek kept a journal in order to document the research team members’ bracketing throughout the study. The journal also noted the connection and validation that Bevly experienced in interviewing participants and the care and mindfulness to not insert her personal experiences, especially regarding the overlapping roles of client and counselor as well as feelings of vulnerability.

Procedure
     We obtained IRB approval before participant recruitment. Eligibility for the study included identifying as a licensed professional counselor (LPC) aged 18 or older who utilized counseling services with a licensed mental health therapist either currently or within the previous 3 years (similar criteria to Yaites, 2015). We used purposive sampling to select participants for this phenomenological study (Hays & Singh, 2023), recruiting participants through email, word of mouth, and networking with LPCs in a 50-mile radius of our institution, which is located in a large state in the Southwestern United States. This radius allowed us to intentionally reach more diverse areas of the geographical region. We also recruited participants through personal contacts and professional counseling organizations. Potential participants completed an eligibility online survey via Qualtrics. We contacted them via phone or email to explain the study and confirm their eligibility. We excluded participants who reported holding expired LPC licenses, experienced therapy more than 3 years ago, or described personal therapy from an individual without a license in a mental health profession. We scheduled face-to-face meetings with participants in their professional counseling office at their convenience. Although participants read and acknowledged the informed consent before meeting face-to-face, we readdressed informed consent before proceeding. Bevly conducted and audio recorded 60-minute interviews with each participant. At the conclusion of each interview, Bevly also facilitated a sand tray activity with the participant.

Participants
     We recruited participants based on gaining depth with adequate sampling (Prosek & Gibson, 2021). Participants (N = 13) identified mostly as White, cisgender women with an average age of 37.23; see Table 1 for complete demographics. Although we sought to recruit participants with diverse social identities, geographic limitations presented a challenge. Thus, our findings should be interpreted with caution, as the external validity, or generalizability, of the findings to other populations or different contexts is impacted by the limited diversity among our participant demographics. Lastly, we asked participants to choose pseudonyms in an effort to protect their anonymity and confidentiality.

Data Sources
Demographic Form
     In order to determine eligibility and collect demographic information, we asked potential participants to complete a Qualtrics survey, an online initial screening tool that included questions about age, gender, racial and ethnic identification, sexual orientation, religious/spiritual identity, number of personal therapy sessions completed, length of time since termination of personal therapy (if applicable), number of years as an LPC, disability status, licensure of therapist, therapist demographic information, and whether or not their counseling training program required personal therapy. The online demographic survey also included information about informed consent and confidentiality. Although it was not required for the study, all participants reported that therapy took place face-to-face. 

Table 1
Participants of the Study

Participant Age Race/Ethnicity Gender Religious/Spiritual Affiliation Sexual Orientation
Alma 37 Latina Woman Christian Heterosexual
Amy 30 Latina Woman Christian Heterosexual
Ashley 29 Multiracial Woman Spiritual Heterosexual
Betty 55 White Woman None Heterosexual
Elenore 30 Multiracial Woman Christian Queer
Felicity 44 White Woman Christian Heterosexual
Jennifer 40 White Woman Christian Heterosexual
Liz 35 White Woman Pagan Bisexual
Lynn 48 White Woman Christian Heterosexual
Michelle 37 White Woman Christian Heterosexual
Rose 30 White Woman Christian Heterosexual
Sophia 35 White Woman None Heterosexual
Thomas 34 White Man None Heterosexual


Semi-Structured Interview Protocol
     We developed a semi-structured interview protocol to guide the interviews. We drafted the questions based on existing literature concerning counselors and personal therapy. The protocol consisted of six open-ended questions and follow-up prompts to understand the experiences of professional counselors who have engaged in personal therapy (see Table 2).

Table 2
Interview Protocol

Grand tour question:
Please tell me about your experience in personal therapy in as much detail as you feel comfortable sharing.
            Follow-up:

What motivated you to seek personal therapy?

What was happening in your life at the time?

How did you go about selecting a therapist?

Can you tell me about what your internal process (thoughts/feelings) was like leading up to your decision to seek personal therapy?
What outcomes did you experience as a result of personal therapy?
How, if at all, has personal therapy affected your personal growth?
How, if at all, has personal therapy affected your own clinical work?
Describe the experience of being both a client and a counselor.

Some literature suggests that counselors feel stigmatized when seeking personal therapy. What do you make of this? How is that similar or different for you?
Is there anything else that you would like to share?

 

Sand Tray Activity
     Hays and Singh (2023) stated that “visual methods in general provide participants the opportunity to express themselves in a nonverbal manner that may access deeper aspects of their understanding and/or experience of a phenomenon” (p. 332). After the semi-structured interview, Bevly invited participants to create their personal therapy experience in a sand tray using the figures and materials provided. This method is consistent with Measham and Rousseau (2010), who used sand trays as a method of data collection for understanding the experiences of children with trauma. The sand trays were documented by digital photos (see Appendix), and participants’ discussions about their creations are part of the audio recordings.

Data Analysis
     We sent the audio recordings to a professional transcriptionist for transcription of each interview and sand tray session. We reviewed transcripts while listening to the recordings for participants’ tone and to verify accuracy. Consistent with phenomenological procedures, the research team conducted data analysis according to an adaptation of classic analysis (Miles et al., 2019), in which three main activities take place: data reduction, data presentation, and conclusion or verification.

Prior to initial coding, the research team completed several tasks in order to develop the preliminary coding manual: taking notes, summarizing notes, playing with words, and making comparisons (Miles et al., 2019). Taking notes involved the research team as well as Bevly’s own independent analysis of a subset of the first three interviews and sand tray explanation transcripts. We divided the transcripts into 10-line segments and wrote notes in the margins. The research team noted our initial reactions to the material.

Summarizing notes involved discussion between the team regarding our reactions to the interview material. We compared and contrasted our margin notes and highlighted shared perspectives and inconsistent viewpoints in a summary sheet. To play with words, we generated metaphors based on our summary sheet. We developed phrases that represented our interpretation of the participants’ interview responses.

During the making comparisons task, we compared and contrasted the key phrases developed in the previous step and grouped them into categories. The team then facilitated reduction of the data as we combined similar phrases and merged overlapping categories. Hays and Singh (2023) asserted the importance of sieving the data to eliminate redundancy. We continued to merge categories and reformat the category headings. From this process, we developed preliminary themes based on the data. To develop initial codes, we established agreement by independently applying the preliminary codes to a subset of three interviews. The research team met weekly to discuss inconsistencies and points of agreement, adjust the preliminary codes, and reapply them to the data subset. We continued to discuss any remaining discrepancies and concerns until we reached a mean agreement of 86% to 90% (Creswell & Creswell, 2017). We reached a mean agreement of 95.1% and then finalized the codes to use in our coding manual.

It is important to note that the research team sensed that we had reached saturation during the final coding process once we began to read the same comments repeatedly in the participant transcripts. In final coding, we applied the final coding manual to each of the interviews and sand tray explanations. We used the same coding manual for both the interviews and the sand tray explanations. The same research team member coded both the interview and sand tray explanation for the same participant. Bevly coded all 13 interviews and sand tray explanations; all four research team members coded the first three interviews and sand tray explanations. Two research team members coded interviews and sand tray explanations 4 through 8, and the other two research team members coded interviews and sand tray explanations 9 through 13. The research team’s finalized codes included the meaning and depth of participants’ experiences in personal therapy. However, if necessary, researchers could still recode during final coding to maintain consistency with the revised definitions (Creswell & Creswell, 2017). When recoding occurred, we reviewed previously analyzed transcripts with the updated codebook on four occasions. Once we completed final coding, Bevly performed member checks with the participants.

Establishing Trustworthiness
     To develop trustworthiness in qualitative research, Lincoln and Guba (1985) presented four criteria: credibility, transferability, dependability, and confirmability. We established credibility in this study through the use of research partners in debriefing, researcher reflexivity, and participant checks. Participant checks occurred after we completed final coding. In this process, we emailed all participants a summary of the identified themes and inquired if the summary portrayed an accurate representation of the experience. Nine out of 13 participants responded and informed Bevly that no adjustments were necessary because the summary adequately captured their experiences. The remaining four participants did not respond to the follow-up email. Additionally, we utilized researcher partners in debriefing and data analysis steps to strengthen the development of the coding manual. In relation to researcher reflexivity, we bracketed our experiences by reflecting on biases and assumptions as counselors who experienced personal therapy through journaling and discussing assumptions with each other, particularly those related to positive personal experience in our own counseling. We demonstrated transferability by openly and honestly providing information about the researchers, the proposed study’s context, the participants, and study methods. This transparency allows readers to have a sense of the context when interpreting findings. We achieved dependability through documenting each task that we completed for the study by keeping an audit trail, allowing for replication. Additionally, the use of multiple data sources, including the demographic survey, interviews, and sand trays, increased the complexity of analysis (i.e., dependability). Also, we provided an in-depth description of our methodology to increase dependability of the study, including information about sample size, data collection, and data analysis that the research team used. Lastly, confirmability was based on an acknowledgement that we, as the primary researchers, cannot be truly objective (Cope, 2014). However, we triangulated the findings using participant checks, consultation with colleagues, and research team consensus to facilitate confirmability.

Findings

The research team identified six major themes and 11 subthemes (see Table 3). The six major themes were: (a) presenting concerns, (b) therapist attributes, (c) intrapersonal growth, (d) interpersonal growth, (e) therapeutic factors, and (f) challenges. We present the subthemes in more detail in the following sections using participant data as supporting evidence.

Table 3
Themes and Subthemes 

Themes Subthemes
Theme 1: Presenting concerns Subtheme 1a: Mental health

Subtheme 2a: Life transitions
Theme 2: Therapist attributes Subtheme 2a: Practicality

Subtheme 2b: Quality
Theme 3: Intrapersonal growth Subtheme 3a: Cognitive

Subtheme 3b: Emotional
Theme 4: Interpersonal growth Subtheme 4a: Personal

Subtheme 4b: Professional
Theme 5: Therapeutic factors Subtheme 5a: Nurturing

Subtheme 5b: Normalization

Subtheme 5c: Vulnerability

Subtheme 5d: Transference
Theme 6: Challenges Subtheme 6a: Finances

Subtheme 6b: Stigma

Subtheme 6c: Role adjustment

 

Theme 1: Presenting Concerns
     Presenting concerns included participants’ thoughts and feelings prior to engaging in personal therapy. Participants shared their decision-making processes and motivations leading to the initiation of personal therapy. Participants described two subthemes that captured their motivation to engage: mental health concerns and life transitions. Mental health concerns represented grief, trauma, anxiety, depression, emotional dysregulation, and relational stressors. For example, Michelle shared:

I would say those were the times when it was like I was pulled to my end, and so the depression, it was like I needed something else more than just the regular support from family and friends and then the miscarriages. It was like I felt so isolated, and then with my dad dying it was like I, gosh, this is . . . it was like both of them dying so close together.

     Participants also described life transitions that served as motivation to engage in personal therapy, such as changes in relationships, careers, and living arrangements. As Lynn represented,

some of that was related to like, as a result of the divorce. I’ve moved three times in the past, like sold a house and moved out of it or kind of moved into storage while in that house in order to be able to stage it and sell it. Then out of the house into an apartment, out the apartment into a rent house. And so there’s been a lot of upheaval for me and for my child.

     Presenting concerns may also be interactional in nature. For some participants (n = 10), life transitions overlapped with their mental health concerns, such as a career change triggering anxiety. However, the remaining three participants cited either mental health concerns or life transitions as a reason for initiating personal therapy. All participants differentiated their experience of internal mental health distress and external life stressors.

Theme 2: Therapist Attributes
     As participants reflected on the different feelings and thought processes they experienced during the initiation of personal therapy, they also shared different attributes they looked for in a therapist. Two subthemes emerged: practicality and quality. Practicality involved factors such as location and affordability. Quality consisted of therapist credentials, training, experience, and specialty areas. All participants shared factors related to both subthemes, including Liz and Alma:

So I was like, “Okay. Well I know this person, I know this person, I know this one. Oh. I don’t know this person, okay. Let’s see if they have an opening.” I wanted someone that was close to my work because it’s easier for me just to go straight from work considering working at a hospital, I can work ridiculously long hours. Sometimes, you know, 12-hour days . . . so I needed someone in [city withheld], and I needed someone I didn’t know. (Laughs) And they took my insurance. (Liz)

I really wanted somebody who was not an intern and not a grad student. I need somebody who was fully licensed. I was looking for somebody who’d done their own work. I wouldn’t really know, but I can kind of tell. I was looking for somebody who had done their own work, their own process, and somebody who’d work with therapists. And so the first therapist that I found, she’d been a therapist for about 12 years. She had a successful private practice on her own. (Alma)

     Some participants (n = 8) prioritized affordability and location over other attributes, while other participants (n = 5) emphasized education, specialty area, and recommendations as their way of selecting therapists. Each participant highlighted their need for accessibility and a good fit into their hectic schedules and personal lives. Participants described these factors as a method of narrowing down the pool of possible therapists.

Theme 3: Intrapersonal Growth
     All participants expressed changes in thoughts related to self that were associated with increased perspective represented by the theme of intrapersonal growth and narrowed into subthemes of cognitive and emotional. Participants specifically reported cognitive intrapersonal growth through internal changes such as awareness, mindfulness, and a sense of purpose as outcomes of receiving personal therapy. Twelve participants described these cognitive changes as a positive experience. Jennifer described the experience as distressing due to the increased awareness of unpleasant knowledge of self and others:

I think a lot of self-awareness in the sense of why I function the way I function and an understanding of why, not only the why, but what I was needing and what I was seeking. And so, just a greater understanding of those pieces that I really had no awareness of before that. . . . I had a little awareness of it, I should say. I probably knew a little bit, but I don’t think I trusted myself in seeing that, trust in myself, trust in my intuition, and trust in my decision-making.

     All participants described emotional intrapersonal growth within themselves related to regulation, stability, and expression as a result of personal therapy. Participants reported a decrease in distressing emotion, increased attunement to their emotional well-being, and an increased ability to express emotions in a healthier manner. Additionally, participants experienced fewer negative feelings toward themselves, including Thomas, who shared, “Back then I was just hiding from a lot of pain. I was hiding a lot of pain. So now I’ve been able to work through that in therapy, I’m just more emotionally attuned in general.”

All participants expressed the overlap between cognitive and emotional intrapersonal growth; furthermore, participants explained how this intrapersonal growth that occurred as a result of personal therapy carried over into other relationships. Participants shared that these internal benefits influenced external factors in their lives. Thus, the theme of intrapersonal growth led directly into the fourth theme, interpersonal growth.

Theme 4: Interpersonal Growth
     All participants shared interpersonal growth, changes in relationships, and depth of social connection, both in their personal relationships and their professional relationships with clients. Participants reflected on how their growth affected relationships with romantic partners, family, friends, and clients. As a result, the two subthemes of personal relationships and professional relationships arose in the data, as expressed by Betty and Thomas:

I believe that it helped me connect with people on a deeper level. Because it’s hard to empathize or connect with someone if you can’t feel yourself. ‘Cause if you can’t feel yourself, you can’t feel what they’re feeling either. So, with my kids, I would be able to first of all, set firmer boundaries with them. And they would take me more seriously. And I’ll then also be able to connect more. And in another area, I was able to learn to ask for help. . . . instead of trying to always take care of things and handle things by myself, and to actually feel safe enough to ask for help. (Betty)

I could empathize. I could play the role of counselor and do my job, but I wasn’t doing it, like “for real for real” . . . I was falling out of what I really needed to be doing, and now I’m able to sit with clients, and every now and then my mind wanders to “oh, I gotta do this or that,” but I’m quick, I become aware of it more quickly, and I’m able to feel deeply with clients. . . . I have sessions all the time now where I’m tearing up with my clients and just feeling so moved by them. And also, I cry more in my personal life and professional life. (Thomas)

     Twelve participants experienced their interpersonal growth as helpful in alleviating their presenting concerns. The remaining participant described the interpersonal growth as tense and uncomfortable. All participants explained that their interpersonal growth in personal relationships was connected to interpersonal growth in professional relationships with their clients. For example, increased boundaries with family extended to increased boundaries with clients. Participants shared that the relationship with their therapist acted as a surrogate for relationships with other people in their lives, which emerged in the therapeutic factors theme.

Theme 5: Therapeutic Factors
     All participants reported avenues of healing within the context of the therapeutic alliance that led to the changes in self and in relationships. Participants reflected on how engaging in the relationship with their therapist facilitated their intrapersonal and interpersonal growth. This theme included four subthemes: nurturing, normalization, vulnerability, and transference. Seven participants described their therapist as nurturing or felt nurtured throughout the process of personal therapy. Participants reported that nurturing meant feeling safe with, trusting of, and cared for by their therapist. This atmosphere of nurturing helped participants foster the courage to take risks without fear of judgment or criticism, as expressed by Jennifer:

I felt prized, and loved, and 100% accepted. And nothing was abnormal or weird, like, what I shared. . . . her response was always super supportive. . . . My schedule was really odd, and so she made it work for my schedule. So, sometimes we met at 7:30 in the morning. Which I really appreciate. Sometimes we met at 8:00, sometimes we met at 2:00 in the afternoon . . . and I never felt like that was a burden . . . she never made it sound like I was burdening her . . . and I’m super appreciative for that.

     All participants reported that their therapist, in different ways, normalized their experience. Many participants (n = 12) believed something was atypical or flawed about their personhood for needing personal therapy. Receiving help triggered feelings of stigma, self-rejection, or self-criticism. Thus, a large part of participants’ healing process was feeling normalized by the therapist. Thomas shared:

There’s even been times when I’ve asked her, like, “do I fit a diagnosis? Like, what’s wrong with me?” You know, there’s even been times when I’ve kind of demanded from her, like “what, what’s the deal? I’ve been seeing you for 2 years, tell me what’s wrong with me.” And she won’t do it. She will not do it, and she’s just like, “No, that’s not what I do.” And so that’s helped me immensely. She’s like “everything you’ve told me, every, everything fits.” And it’s helped me to see it that way.

     Participants also reported feeling vulnerable as the client and described the feeling of opening themselves to the presence and feedback of another as uncomfortable but also inducing growth. Participants described this level of vulnerability as it related to their counselor identity; they explained that they were most accustomed to structuring the session and managing the time and felt more comfortable in the therapeutic relationship in the role of counselor. As the client, participants experienced a new kind of vulnerability that led to intrapersonal and interpersonal growth due to the reversed power differential, as described by Betty:

When I’m the client, it’s like, “I don’t know where we’re going, I don’t know what’s gonna come up.” It’s kind of scary sometimes. Like you know? He’s the guy with the flashlight, and I don’t know where he’s, what’s gonna happen sometimes. Like what’s going to get uncovered, [what] I’m suddenly gonna become aware of or feel, or something. So it’s a little scary.

     Several participants (n = 9) shared that healing occurred as a result of therapeutic transference in the relationship with their therapist. Participants reported perceiving the therapist as a significant relationship in their life, sometimes describing their therapists as a parental presence. At times, the therapists themselves were the healing catalyst, acting as a substitute for redirecting emotional wounds. This subtheme also encompassed feelings of attachment. In many cases, participants’ early attachment figures were either emotionally or physically unavailable or harmful. Participants explained that their therapists acted as a healthy attachment figure and described this aspect of the relationship as reparative. Some participants shared feeling re-parented by their therapist, like Michelle:

She probably was the age of my mom at the time, and so I felt very nurtured by her in a way that, like I always wanted to be nurtured by mom but it hadn’t happened like that. . . . I mean, there was that transference kind of feeling that was happening, but it was very positive and she was very warm, and I feel like that relationship was so healing and allowed me to process through more things, feeling supported and encouraged by someone who is kinda like my mom but not my mom, almost like it was like a reparative thing within the relationship.

Theme 6: Challenges
     Two participants shared that personal therapy was a purely positive experience without negative or uncomfortable feelings. However, 11 participants reported challenges during the course of therapy that inhibited their healing processes. These challenges included three subthemes: finances, stigma, and role adjustment, as explained by Felicity, Michelle, and Rose:

Um and then I kind of thought I was done and then I realized it was like, okay I have to add the money aspect, because every time I’m just like ugh, because I am perpetually broke. And so, I added the money like off to the side just like it’s not really part of the process but it’s this thing that exists that I can’t erase. (Felicity)

There is a stigma like that if you need to go see someone that you’re somehow like inadequate to deal with your own stuff, or that you’re crazy or that you’re really far gone, like only people who are really far gone need to do that, but I still think it’s a pride thing, you know? (Michelle)

It’s weird and it’s distracting as a client because . . . I know what she’s doing. Why is she doing that? Huh. Like it’s a good place to run to if you don’t want to go where they’re trying to take you; you can go into your analytical, left brain, logical mode. Oh, I know exactly, and you feel like an expert. You know what they’re doing. They’re not pulling it over on you. (Rose)

     Five participants discussed the idea of stigma related to their counselor status. The remaining participants (n = 9) explained that they did not personally feel stigmatized, but were aware of the stigma that existed with regard to counselors who receive personal therapy. All participants shared that they would attend personal therapy longer or more frequently if not for financial barriers. Additionally, each participant described the difficulty of experiencing the identity of both client and counselor.

Discussion

We aimed to answer two overarching research questions: 1) What contributes to counselors’ decisions to seek personal therapy? and 2) How do professional counselors make meaning of their experiences in utilizing personal therapy? The results of the current study are both similar and contradictory to previous literature. For example, many researchers have demonstrated evidence of counselor burnout and compassion fatigue (Moore et al., 2020; Robino, 2019; Thompson et al., 2014). Participants described feeling burned out and lacking in empathy as motivations to seek personal therapy. Additionally, Day and colleagues (2017) outlined behavioral symptoms of burnout and compassion fatigue, including mood changes, sleep disturbances, becoming easily distracted, and increased difficulty concentrating. Many participants shared similar symptoms when discussing thoughts and feelings in their decision-making processes to initiate personal therapy, as well as when describing their mental health concerns. Therefore, it is important to assess counselors for levels of burnout and compassion fatigue in addition to raising awareness of their signs and symptoms.

The subtheme of stigma in participant voices within the current study is consistent with the existing literature. Kalkbrenner et al. (2019) found that stigma was one of three primary barriers to counseling among practicing counselors and human service professionals. Participants in our study described the general stigma and personal shame in seeking mental health treatment. Furthermore, participants differentiated between general stigma regarding mental health and stigma specific to counselors. Based on this finding, counselors may experience greater stigma than the general population when seeking personal therapy due to their professional identity. We would also like to note the research team’s personal reactions of feeling affirmed and normalized, as we had all experienced some level of stigma in seeking our own therapy—hearing and reading the participants’ experience of stigma created increased feelings of universality among our team.

With regard to theories about the working alliance, Mearns and Cooper (2017) described the notion of working at the intimate edge of the ever-shifting interface between client and counselor, referring to both the boundary between self and other and the boundary of self-awareness. Most notably in our study, the subtheme of professional interpersonal growth illuminates how the self-awareness gained in therapy impacted participants’ clinical work, supporting the working alliance theory, outlined by Mearns and Cooper (2017), which posits that expanding self-discovery and becoming more intimate with one’s own experience through the evolving relationship with the other increases intimacy in interpersonal relationships as one becomes more attuned to the self.

Aligned with the concept of professional growth, many researchers have emphasized that personal therapy was an educational or training experience for therapists and added to their professional repertoire of knowledge and skills (Anderson & Levitt, 2015; Moe & Thimm, 2021). However, these findings are not congruent with the experiences of participants in the present study. Although participants reported enhanced professional growth in terms of boundaries with clients and professional advocacy outside of the therapeutic relationship, participants shared that the intellectual aspect of personal therapy within the relationship served as a barrier to the healing process. All participants expressed a desire or intent to release themselves of their counselor identity while experiencing the client role. Thus, some counselors may not see personal therapy as a means for education or professional role modeling and instead find those aspects as distracting to the experience. It is also interesting to note that our research team’s perspectives mirrored this varied experience; through our journaling and discussion, we acknowledged that some research team members shared the experience of participants in our study, while other members felt more similarly to the preexisting literature’s conclusions.

Limitations and Future Research
     The current study includes many strengths, such as the rigor we followed and trustworthiness we demonstrated. However, some limitations exist. Firstly, we collected data prior to the pandemic; a replication study post–COVID-19 could shed light on specific factors related to how the pandemic has impacted counselors’ experiences in personal therapy. Additionally, we used a single interview design, which limits the amount of extended field experience with participants. Participants may have offered more intimate and sensitive information after spending more time in the interviewing process. Due to the sensitive nature of the topic of the study, we worked to establish trust and build rapport with the participants by using introductory questions at the beginning of the interview. Researchers may collect richer data through the use of longitudinal studies that examine participants’ experiences in personal therapy over time and with other data sources. Despite plans to recruit a sample that was diverse in terms of age, gender, ethnic identification, sexual orientation, and religious/spiritual orientation, participants in this study were similar to each other. Only one participant identified as a man, and the majority of participants (n = 9) were White. We attempted to rectify the above limitations through networking with licensed professional counselors who worked in a variety of counseling settings. However, future researchers could examine the experience of counselors who identify as men or non-binary, as well as counselors of color.

Implications for Counselors
     The knowledge gained from our study offers both suggestions for how clinicians can approach counselors in personal therapy and broader advocacy for the profession to increase engagement in counseling. In terms of clinical practice, participants often emphasized the struggle in assuming the client role, as they were most comfortable with the typical power differential in their professional work. This phenomenon was especially salient in the participant voices of this study; vulnerability and role adjustment were crucial themes of their experience. Therefore, it may behoove clinicians to maintain awareness of this possibility or discuss it within personal therapy. For example, Moore et al. (2020) suggested engaging in conversations about interpersonal stress, self-care, and burnout within the supervision relationship; however, we purport that clinicians of clients who are also counselors could facilitate intentional space to address these issues in counseling. That being said, mental health professionals may find benefit in balancing attending to the person of the counselor with focus on professional identity due to the barrier of role adjustment presented in this study. Neswald-Potter and colleagues (2013) suggested the use of the Wheel of Wellness Model developed by Witmer and Sweeney (1992) to facilitate an integrated approach in promoting wellness in counselors: spirituality, self-direction, work and leisure, friendship, and love. Finding meaning in all life tasks could assist clinicians in balancing professional and personal concerns in working with counselors as clients. Wellness is often associated with self-care practices in counseling.

Self-care is not a novel topic of discussion in counselor training or professional practice. However, in light of this study’s findings, we aim to describe therapeutic interventions for mental health professionals who may have counselors as clients. Coaston (2017) summarized much of the literature on self-care for counselors and recommended several strategies for interventions in three main areas: mind, body, and spirit. Concretely, interventions may include mindfulness, boundary setting, time management, cognitive reappraisal writing activities, stretching, moral inventory, and listing life principles (Coaston, 2017; Posluns & Gall, 2020). Finally, Bradley et al. (2013) outlined a variety of creative approaches to counselor self-care, as well as facilitative questions that may lend well to opening dialogue in a therapy session. Example questions include: (a) What are the indications that you are doing well and healthy? (b) Which things in the environment can be changed to help you continue to grow? and (c) Do you experience this emotion or pattern of emotions frequently? How did you respond? These suggested self-care interventions are only useful if counselors attend personal therapy, and in the results of our study, participants described how stigma remained a barrier.

Clinicians may consider normalizing thoughts and feelings related to stigma in order to encourage engagement in counseling. Sommers-Flanagan and Sommers-Flanagan (2018) defined normalization as the therapist’s use of indirect or direct statements that reframe client problems as contextual responses to the difficulties of life. Therapists use normalization to depathologize client concerns and convey implicit acceptance of the person of the client. Varying degrees of normalization skills include psychoeducation, reframing, and self-disclosure (Sommers-Flanagan & Sommers-Flanagan, 2018). Reducing the stigma of accessing counseling as a counselor may need to begin with normalizing it during training. Knaak et al. (2014) reported that the most effective anti-stigma interventions incorporate social contact, education, personal testimonies, teaching skills, and myth-busting. Therefore, creating space for anti-stigma interventions in professional development activities (e.g., conference presentations, continuing education sessions) as well as incorporating these strategies into counselor training (e.g., class or group supervision) may advocate for engagement in counseling across the counselor profession spectrum. Additionally, a follow-up study examining counselors seeking therapy to improve their own clinical efficacy with clients may also serve as a way to decrease stigma.

Lastly, we believe that the findings of our study support the need for and advocacy of personal therapy after graduate training. Unlike counselor trainee program requirements that often mandate a certain number of hours in personal therapy, fully licensed professional counselors are not regulated by licensing boards with regard to continuing personal therapy. Policy changes that include a personal therapy requirement in a similar vein as continuing education credits may positively impact counselor stigma and wellness.

Conclusion

Counselors face many challenges in their clinical work, including occupational stressors and the need for self-awareness (Moore et al., 2020; Mullen et al., 2017; Prosek et al., 2013; Robino, 2019; Thompson et al., 2014). The current descriptive phenomenological study serves to provide an understanding of the lived experiences of counselors who utilize personal therapy, including their motives to engage and meaning made while engaged. We offer clinical suggestions within the counseling relationship, steps to reduce stigma, and recommendations for facilitating self-care strategies among counselor trainees and professional counselors directly from voices of counselors who have accessed personal therapy.

 

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

References

Anderson, R. S., & Levitt, D. H. (2015). Gender self-confidence and social influence: Impact on working alliance. Journal of Counseling & Development, 93(3), 280–288. https://doi.org/10.1002/jcad.12026

Bradley, N., Whisenhunt, J., Adamson, N., & Kress, V. E. (2013). Creative approaches for promoting counselor self-care. Journal of Creativity in Mental Health, 8(4), 456–469. https://doi.org/10.1080/15401383.2013.844656

Coaston, S. C. (2017). Self-care through self-compassion: A balm for burnout. The Professional Counselor, 7(3), 285–297. https://doi.org/10.15241/scc.7.3.285

Council for the Accreditation of Counseling and Related Educational Programs. (2023). 2024 CACREP standards. https://www.cacrep.org/wp-content/uploads/2023/06/2024-Standards-Combined-Version-6.27.23.pdf

Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). SAGE.

Day, K. W., Lawson, G., & Burge, P. (2017). Clinicians’ experiences of shared trauma after the shootings at Virginia Tech. Journal of Counseling & Development, 95(3), 269–278. https://doi.org/10.1002/jcad.12141

Fulton, C. L., & Cashwell, C. S. (2015). Mindfulness-based awareness and compassion: Predictors of counselor empathy and anxiety. Counselor Education and Supervision, 54(2), 122–133. https://doi.org/10.1002/ceas.12009

Gleason, B. K., & Hays, D. G. (2019). A phenomenological investigation of wellness within counselor education programs. Counselor Education and Supervision, 58(3), 177–194. https://doi.org/10.1002/ceas.12149

Hays, D. G., & Singh, A. A. (2023). Qualitative research in education and social sciences. Cognella.

Ivers, N. N., Johnson, D. A., Clarke, P. B., Newsome, D. W., & Berry, R. A. (2016). The relationship between mindfulness and multicultural counseling competence. Journal of Counseling & Development, 94(1), 72–82. https://doi.org10.1002/jcad.12063

Kalkbrenner, M. T., Neukrug, E. S., & Griffith, S.-A. M. (2019). Appraising counselor attendance in counseling: The validation and application of the Revised Fit, Stigma, and Value Scale. Journal of Mental Health Counseling, 41(1), 21–35. https://doi.org/10.17744/mehc.41.1.03

Knaak, S., Modgill, G., & Patten, S. B. (2014). Key ingredients of anti-stigma programs for health care providers: A data synthesis of evaluative studies. The Canadian Journal of Psychiatry, 59(1 suppl), 19–26. https://doi.org/10.1177/070674371405901S06

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. SAGE.

Mearns, D., & Cooper, M. (2017). Working at relational depth in counselling and psychotherapy (2nd ed.). SAGE.

Measham, T., & Rousseau, C. (2010). Family disclosure of war trauma to children. Traumatology, 16(4), 85–96. https://doi.org/10.1177/1534765610395664

Merriman, J. (2015). Enhancing counselor supervision through compassion fatigue education. Journal of Counseling & Development, 93(3), 370–378. https://doi.org/10.1002/jcad.12035

Miles, M. B., Huberman, A. M., & Saldaña, J. (2019). Qualitative data analysis: A methods sourcebook (4th ed.). SAGE.

Moe, F. D., & Thimm, J. (2021). Personal therapy and the personal therapist. Nordic Psychology, 73(1), 3–28.
https://doi.org/10.1080/19012276.2020.1762713

Moore, C. M., Andrews, S. E., & Parikh-Foxx, S. (2020). “Meeting someone at the edge”: Counselors’ experiences of interpersonal stress. Journal of Counseling & Development, 98(2), 123–135. https://doi.org/10.1002/jcad.12307

Moustakas, C. (1994). Phenomenological research methods. SAGE.

Mullen, P. R., Morris, C., & Lord, M. (2017). The experience of ethical dilemmas, burnout, and stress among practicing counselors. Counseling and Values, 62(1), 37–56. https://doi.org/10.1002/cvj.12048

Neswald-Potter, R. E., Blackburn, S. A., & Noel, J. J. (2013). Revealing the power of practitioner relationships: An action-driven inquiry of counselor wellness. The Journal of Humanistic Counseling, 52(2), 177–190. https://doi.org/10.1002/j.2161-1939.2013.00041.x

Orlinsky, D. E. (2013). Reasons for personal therapy given by psychoanalytically oriented psychotherapists and their effects on personal wellbeing and professional development. Psychoanalytic Psychology, 30(4), 644–662. https://doi.org/10.1037/a0034587

Pompeo, A. M., & Levitt, D. H. (2014). A path of counselor self-awareness. Counseling & Values, 59(1), 80–94. https://doi.org/10.1002/j.2161-007X.2014.00043.x

Posluns, K., & Gall, T. L. (2020). Dear mental health practitioners, take care of yourselves: A literature review on self-care. International Journal for the Advancement of Counselling, 42, 1–20. https://doi.org/10.1007/s10447-019-09382-w

Prosek, E. A., & Gibson, D. M. (2021). Promoting rigorous research by examining lived experiences: A review of four qualitative traditions. Journal of Counseling & Development, 99(2), 167–177. https://doi.org/10.1002/jcad.12364

Prosek, E. A., Holm, J. M., & Daly, C. M. (2013). Benefits of required counseling for counseling students. Counselor Education & Supervision, 52(4), 242–254. https://doi.org/10.1002/j.1556-6978.2013.00040.x

Rake, C., & Paley, G. (2009). Personal therapy for psychotherapists: The impact on therapeutic practice. A qualitative study using interpretative phenomenological analysis. Psychodynamic Practice, 15(3), 275–294. https://doi.org/10.1080/14753630903024481

Remley, T. P., Jr., & Herlihy, B. (2020). Ethical, legal and professional issues in counseling (6th ed.). Merrill.

Robino, A. E. (2019). Global compassion fatigue: A new perspective in counselor wellness. The Professional Counselor, 9(4), 272–284. https://doi.org/10.15241/aer.9.4.272

Rosin, J. (2015). The necessity of counselor individuation for fostering reflective practice. Journal of Counseling & Development, 93(1), 88–95. https://doi.org/10.1002/j.1556-6676.2015.00184.x

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (3rd ed.). Wiley.

Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2022). Counseling the culturally diverse: Theory and practice (9th ed.). Wiley.

Thompson, I. A., Amatea, E. S., & Thompson, E. S. (2014). Personal and contextual predictors of mental health counselors’ compassion fatigue and burnout. Journal of Mental Health Counseling, 36(1), 58–77. https://doi.org/10.17744/mehc.36.1.p61m73373m4617r3

Tufekcioglu, S., & Muran, J. C. (2015). Case formulation and the therapeutic relationship: The role of therapist self-reflection and self-revelation. Journal of Clinical Psychology, 71(5), 469–477. https://doi.org/10.1002/jclp.22183

VanderWal, B. L. (2015). The relationship between counselor trainees’ personal therapy experiences and client outcome (Publication No. 1199) [Doctoral dissertation, Western Michigan University]. https://scholarworks.wmich.edu/dissertations/1199

Witmer, J. M., & Sweeney, T. J. (1992). A holistic model for wellness and prevention over the life span. Journal of Counseling & Development, 71(2), 140–148. https://doi.org/10.1002/j.1556-6676.1992.tb02189.x

Yaites, L. D. (2015). The essence of African Americans’ decisions to seek professional counseling services: A phenomenological study [Doctoral dissertation, University of North Texas]. https://digital.library.unt.edu/ark:/67531/metadc804978

 

Appendix



 

Dax Bevly, PhD, is core faculty at Antioch University Seattle. Elizabeth A. Prosek, PhD, NCC, LPC, is an associate professor at The Pennsylvania State University. Correspondence may be addressed to Dax Bevly, Antioch University Seattle, School of Applied Psychology, Counseling, and Family Therapy, 2400 3rd Ave #200, Seattle, WA 98121, dbevly@antioch.edu.

“A Learning Curve”: Counselors’ Experiences Working With Sex Trafficking

Jan 17, 2024 | Volume 13 - Issue 4

Claudia G. Interiano-Shiverdecker, Devon E. Romero, Katherine E. McVay, Emily Satel, Kendra Smith

In this transcendental phenomenological study, we interviewed 10 counselors who have clinical experience working with sex trafficking survivors. Through in-depth individual interviews, participants discussed their lived experiences providing counseling to this population. Our analysis revealed four primary themes: (a) counselor knowledge: “learning curve,” (b) counselor skills: “creating a safe space to dive into work,” (c) counselor attitudes: “being able to listen to the client’s story,” and (d) counselor action: “more than just a counselor.” The findings indicated that counselors working with sex trafficking survivors needed to understand and address the different aspects of trauma. Our findings also demonstrate that working with sex trafficking survivors requires additional competencies such as recognizing the signs of sex trafficking, vulnerable populations, and the processes by which traffickers force people into sex trafficking. We discuss these findings in more detail and identify implications for counselor training and practice.

Keywords: sex trafficking survivors, counseling, phenomenological, trauma, competencies

Sex trafficking of any individual is a significant concern globally. In 2000, the United States government enacted the Victims of Trafficking and Violence Protection Act of 2000, which defined sex trafficking as “the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery” or “when the person induced to perform such act has not attained 18 years of age” (§ 103). Although the United States’s efforts fully meet the minimum standards established by the Victims of Trafficking and Violence Protection Act of 2000 to eliminate severe forms of trafficking, the Department of Justice initiated a total of 210 federal human trafficking prosecutions in 2020, of which 195 involved predominantly sex trafficking (U.S. Department of State, 2021). As stated in the Trafficking in Persons Report (U.S. Department of State, 2021), all 50 states, the District of Columbia, and U.S. territories have reported all forms of human trafficking over the past 5 years. With an estimated 4.8 million people victimized by sex trafficking (International Labour Organization, 2017), it is important to understand how counselors identify, provide services to, and advocate on behalf of sex trafficking survivors within the counseling setting. 

Sex Trafficking and Mental Health
     As a form of human trafficking, sex trafficking exposes individuals to torture; kidnapping; and severe psychological, physical, and sexual abuse. Physical health consequences of sex trafficking include general health complications (e.g., malnutrition), reproductive health consequences (e.g., sexually transmitted diseases, unwanted pregnancies), substance abuse, and physical injuries (Grosso et al., 2018; Lutnik, 2016; Muftić & Finn, 2013). Psychological abuses are numerous and can include intimidation, threats against loved ones, lies, deception, blackmail, isolation, and forced dependency (Thompson & Haley, 2018).

Constantly experiencing atrocious physical and psychological abuses creates mental health consequences such as depression, post-traumatic stress, dissociation, irritability, suicidal ideation, self-harm, and suicide (Cole et al., 2016; O’Brien et al., 2017). Survivors of sex trafficking may exhibit severe mental illness, including schizophrenia and psychotic disorders, increased risk of compulsory psychiatric admission, and longer duration of psychiatric hospitalizations (Oram et al., 2016). Moreover, social distancing and the global economic downturn due to the COVID-19 pandemic increased online sexual exploitation and the number of individuals vulnerable to sex trafficking (U.S. Department of State, 2021).

Because of the prevalence of sex trafficking, the health consequences that result from it, and the diverse areas in which counselors practice (e.g., community clinics, private practices, behavioral health departments, college/universities, K–12 schools), counselors must be prepared to work with sex trafficking survivors (Interiano-Shiverdecker et al., 2022, 2023; Litam, 2017, 2019; Romero et al., 2021; Thompson & Haley, 2018). Standards required by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) prepare counselors to demonstrate clinical competencies to address a variety of circumstances, including traumatic experiences, across various continuums of care (e.g., inpatient, outpatient). Clinical mental health counselors with specialization in substance abuse and marriage, couple, and family counseling can also address other comorbid issues typically encountered with sex trafficking clients such as substance abuse and relational difficulties (CACREP, 2015; Litam & Lam, 2020). Early incidence of sex trafficking (12–16 years for girls, 11–13 for boys and transgender youth; Franchino-Olsen, 2019) demands the attention of school counselors trained to promote the academic, career, and personal/social development of school-aged children (American School Counselor Association [ASCA], 2022; CACREP, 2015). Therefore, first-hand accounts of counselors providing services to this population can provide an overview of current needs, challenges, and recommendations for clinical practice and research.

Sex Trafficking Research in the Counseling Profession
     A recent review of the literature showed increased attention to sex trafficking coverage in top-tier counseling journals. Conceptual pieces reviewed relevant information on sex trafficking, counselor awareness, and counseling implications (Browne-James et al., 2021; Burt, 2019; Litam, 2017; Thompson & Haley, 2018). Empirical studies explored counselors’ attitudes toward sex trafficking (Litam, 2019; Litam & Lam, 2020), assessment for the screening of sex trafficking (Interiano-Shiverdecker et al., 2022, 2023; Romero et al., 2021), mental health treatment programs and modalities for sex trafficking (Johnson, 2020; Kenny et al., 2018; Schmidt et al., 2022; Woehler & Akers, 2022), and survivors’ recovery stories (Bruhns et al., 2018). Thompson and Haley (2018) reported a need for more training and education for counselors on sex trafficking. In a study done by Litam and Lam (2020), results indicated that counselor training in sex trafficking increased awareness. As a response, Interiano-Shiverdecker et al. (2023) developed an initial list of child sex trafficking competencies for counselors.

Although these studies provide relevant information for counselors’ work with sex trafficking, they do not focus on the experience of providing care for sex trafficking victims and survivors. Exploring counselors’ experiences provides a significant breakdown of current mental health care for this population. In other words, what does providing care for this population look and feel like in reality and what competencies work when serving sex trafficking victims and survivors? Only one phenomenological study focused on this inquiry, but this study examined therapists’ experiences working with foreign-national survivors of sex trafficking in the United States (Wang & Park-Taylor, 2021). Although this study presents important findings, it explored counselors’ work with only a certain group of sex trafficking individuals. Despite incomplete records, most data indicate that U.S. citizens are equally vulnerable to sex trafficking. For example, the National Human Trafficking Hotline (n.d.), which maintains one of the most extensive data sets on human trafficking in the United States, indicates that U.S. citizens comprised approximately 40% of their callers. The current study seeks to expand on the work of Wang and Park-Taylor (2021) by obtaining first-hand accounts of counselors providing services to sex trafficking clients in the United States and providing an overview of needs, challenges, and recommendations for clinical practice and research. The guiding research question for this study was: What are the lived experiences of counselors working with sex trafficking survivors in the United States?

Method

Using transcendental phenomenological research, the researchers—Claudia G. Interiano-Shiverdecker, Devon E. Romero, Katherine E. McVay, Emily Satel, and Kendra Smith—sought to understand counselors’ experiences working with sex trafficking survivors. A transcendental phenomenological method was best suited for this study because it allowed us to provide thick descriptions of the phenomena while employing bracketing techniques to explore participants’ experiences outside of our perspectives (Hays & Singh, 2012). Utilizing Moustakas’s (1994) modification of Van Kaam’s method, we sought to explore the occurrences of counselors working with sex trafficking survivors and collectively met to address any biases that came up during data analysis.

Researchers as Instruments
     At the time of the study, Interiano-Shiverdecker and Romero were counselor educators at a university in the Southern United States with recent sex trafficking publications and experience working with youth vulnerable to sex trafficking in community and school settings. McVay was a doctoral candidate and a licensed professional counselor who was practicing as a social–emotional wellness counselor at a private school. Satel and Smith were master’s students in a clinical mental health program. Our desire to explore this topic stemmed from a limited discussion of sex trafficking in the literature and sought to include the voices of counselors. As the research team, we are all involved in a research lab dedicated to understanding sex trafficking and how counselors can better serve sex trafficking survivors. As such, we had varying levels of experience with research and engagement with sex trafficking. Satel and Smith were new to research, including topics surrounding sex trafficking. Therefore, Interiano-Shiverdecker and Romero’s broader understanding of the topic could have influenced newer members. For example, Interiano-Shiverdecker assumed that codes would resemble counseling competency categories (e.g., knowledge, skills, awareness). To reduce researcher bias, we engaged in weekly debriefing meetings for approximately 5 months for ongoing discussion of our perspectives and preconceived notions throughout data analysis. We documented our biases in journals, checked in on them during meetings, and referenced participants’ quotes to prevent imposing our assumptions of the data.

Participants and Sampling
     After receiving IRB approval from the university, we sought participants through purposeful sampling and snowball sampling. Purposeful sampling strategies included reaching out directly via email to counselors who fit the study criteria and sending two calls for participants on an email mailing list for counselors and counselor educators (i.e., CESNET). For direct emails, McVay created a list of individuals who fit the criteria from Interiano-Shiverdecker and Romero’s professional network and an internet search. We also engaged in snowball sampling methods through recruited participants involved in the study. Inclusion criteria included counselors over the age of 18, who had previously or were currently working with children or adults who had been sex trafficked. Participants confirmed meeting the inclusion criteria by responding to a demographic questionnaire before beginning the interview. Following the qualitative researcher’s recommendation of sample size, we sought a range between five and 25 participants for this study (Creswell, 2013; Moustakas, 1994). Counselors who agreed to participate completed the consent forms, a demographic form, and a one-time Zoom interview. Participants received a $25 gift card for their involvement in the study. We recruited for about 5 weeks after interviewing 10 counselors. After the tenth interview was completed and we concluded the first round of analysis for all interviews, we felt that data saturation was achieved when similar codes showed up throughout the data.

The resulting participant pool consisted of 10 counselors (nine female and one male) ranging in age from 27 to 61 years (M = 40.7, Mdn = 38.5, SD = 11.1). Seven participants identified as White, two participants identified as Hispanic, and one participant identified as Asian. The participants also identified their employment setting: university (n = 1), agency (n = 3), and private practice (n = 6). Participants disclosed providing services in one or several states such as Alabama (n = 1), Florida (n = 1), Missouri (n = 1), Nevada (n = 1), North Carolina (n = 1), and Texas (n = 7). One participant also reported providing services to sex trafficking survivors in the United Kingdom. Years working with survivors of sex trafficking ranged from 1 to 13+ years, with a range of three to 50+ clients who disclosed their sex trafficking experience. One participant (Alejandra) who had worked primarily with survivors of sexual abuse did not indicate their number “since a lot of clients I have worked with do not readily admit to being sex trafficked, I’m not sure.” Table 1 outlines participant demographics in more detail.

Table 1
Participant Demographics

Pseudonym Age Gender Race/Ethnicity Work Setting Years of Service # ST Clients CACREP
Kimberly 48 Female White Private Practice 11 30 Yes
John 38 Male White University 11 5 Yes
Stacy 33 Female White Private Practice 8 3+ Yes
Alejandra 54 Female Hispanic Agency Unsure Most of career No
Fen 39 Female Asian Private Practice 5 4 Yes
Cassandra 33 Female White Private Practice 5 50+ Yes
Tiffany 27 Female White Private Practice 1 25 Yes
Amanda 29 Female White Private Practice 4 5 Yes
Ana 61 Female Hispanic Agency 13+ 20 Yes
Cristina 45 Female White Agency 3 10+ No

Note. Years of Service = Years providing services to ST survivors; ST = Sex trafficking; CACREP = Program accredited by the Council for Accreditation of Counseling and Related Educational Programs. 

Data Collection Procedures
To follow phenomenological research methods, Interiano-Shiverdecker trained the doctoral student (McVay) in conducting semi-structured interviews. The researchers developed interview questions based on the purpose of the study and from a review of the literature. Interiano-Shiverdecker and McVay completed the interviews. Following Moustakas’s (1994) recommendations, the interview protocol consisted of 12 semi-structured, open-ended questions that invited an in-depth discussion of their experiences. To create our interview protocol, we reviewed current literature in counseling on sex trafficking, particularly qualitative studies (Browne-James et al., 2021; Bruhns et al., 2018; Johnson, 2020; Wang & Park-Taylor, 2021; Woehler & Akers, 2022). Based on this review and Interiano-Shiverdecker’s experience in qualitative research, we decided to focus not only on counselors’ experiences with working with this population but also on their perspectives on the identification, prevention, and impact of sex trafficking on their clients. The complete interview protocol can be found in the Appendix. Interviews lasted from 26 to 69 minutes in length and occurred via Zoom because data collection occurred in 2021 and it was the most appropriate medium to respect social distancing and obtain a national sample. According to our IRB approval, our data collection presented no more than minimal risks for the participants. All interview questions followed a respectful disposition using open-ended questions to engage participants. However, McVay explained before beginning the interviews that participants could stop, pause, or opt out of the interview if the questions brought too much emotional distress. No participant requested the interview to be stopped or paused. During the interviews, we used counseling skills to facilitate the conversation and to build upon the experiences discussed. We recorded and de-identified all interviews for verbatim transcription.

Participants also completed a demographic questionnaire before the interview to confirm their eligibility for the interview and obtain information on their age, gender, race/ethnicity, work setting, CACREP accreditation and degree, years working with sex trafficking survivors, and the number of clients they worked with who identified as trafficked.

Data Analysis
Utilizing Moustakas’s (1994) modification of Van Kaam’s data analysis, the research team engaged in the seven steps proposed by this approach. Data analysis and management relied on the use of NVivo software (Version 12). Interiano-Shiverdecker provided training in data analysis to McVay, Satel, and Smith. Interiano-Shiverdecker, McVay, Satel, and Smith engaged in the first step by individually analyzing transcripts and engaging in horizontalization of meaning units (Hays & Singh, 2012) to create in vivo codes for all nonrepetitive, nonoverlapping statements (meaning units). Second, we merged all files to determine the invariant constituents through a process of reduction and elimination. This first process of reduction allowed us to determine what was necessary and sufficient data to understand the phenomenon (Moustakas, 1994). The team then assigned themes or clusters of meaning to similar statements (third step). From the clusters of meaning, we created an initial codebook based on the discussions and findings from individual data analysis. We used the initial codebook to examine the themes against the dataset, ensuring that it was representative of participants’ experiences (fourth and fifth steps). As a team, we discussed any disagreements and worked on the data until we achieved a consensus. We worked out disagreements by discussing any opposing views and voting as a group on the best decision. We subsequently created textural descriptions through participants’ verbatim quotes, as well as created structural descriptions by examining the emotional, social, and cultural connections between what participants said (sixth step). Finally, we created composite textural-structural descriptions that outlined the reoccurring and prominent themes across all participants by organizing the themes into subthemes and ensuring that they represented all (if not most) participants’ experiences. After this analysis, we felt we achieved data saturation. After the completion of the initial analysis, Romero reviewed the data as a peer reviewer and offered suggestions. The entire research team reviewed the suggestions and came together to incorporate them until we reached a consensus and developed the final codebook.     

Strategies for Trustworthiness
     To limit the effects of researcher bias, we employed several strategies for trustworthiness. These included reflexive journals, triangulation of researchers, peer debriefers, an external auditor, member checking, and thick descriptions to ensure ethical validation, credibility, transferability, confirmability, sampling adequacy, and authenticity of our analysis (Hays & Singh, 2012). We engaged in reflexive journaling and weekly bracketing meetings during our individual and group data analysis to discuss codes, potential themes, and our assumptions shadowing the participants’ words. Researchers on the team brought varying levels of experience with research and the topic of sex trafficking, which we believe helped balance our subjective analysis of the data. We engaged in two rounds of member checking with the participants, one occurring after the transcription of the interviews and the second one after we wrote the themes. No participants changed the transcription of their interview or disagreed with the presentation of the themes. After the formulation of the themes from the original coding team, Romero served as a peer debriefer and reviewed the themes, key terms, and raw data, allowing participants to make recommendations on the content presented. This division in the research team allowed for another check outside of the original designated research team. An external auditor, a counselor educator with experience in conducting qualitative research, also reviewed the NVivo file and the write-up of the findings. The external auditor agreed with our data analysis procedures and presentation of the findings. He did provide suggestions to reduce the repetition of our first and second themes, which we implemented. Finally, we provide thick descriptions of our data collection and analysis procedures and present our results with direct quotes to ground our work.

Results

We identified four prevalent themes about mental health counselors’ experiences with sex trafficking survivors: (a) counselor knowledge: “learning curve,” (b) counselor skills: “creating a safe space to dive into work,” (c) counselor attitudes: “being able to listen to the client’s story,” and (d) counselor action: “more than just a counselor.” We use pseudonyms to present our results.

Counselor Knowledge: “Learning Curve”
     All participants emphasized the importance not only of understanding trauma but also of gaining sex trafficking–specific knowledge throughout their work with survivors. Tiffany noted a “learning curve” when working with this population, despite working with trauma for most of her career. We categorized this theme into two subthemes: (a) understanding trauma work and (b) understanding sex trafficking and survivors.

Understanding Trauma Work
     To work with sex trafficking, all counselors spoke about the importance of having general knowledge of trauma work. The most prominent topics included multicultural, legal, and ethical considerations. Important multicultural considerations for counselors involve understanding group differences between their clients (e.g., gender, race, age) and working from a culturally sensitive framework. Kimberly emphasized that “we really need people to not only have cultural sensitivity but also encourage those who are of other races to counsel these girls,” adding that “they need someone that’s like them from the same culture . . . to relate culturally to somebody.”  Legal implications included understanding consent, informing clients of their limits of confidentiality when assessing for risk, and their role as mandated reporters. In reference to ethical practices, consultation and supervision arose as with any other trauma work. Stacy noted that it was “important for us to talk to one another if something’s going awry.”

Many participants conveyed how crucial it was for them to understand healing and its complexities. Cristina shared that clients are “going to have their ups and downs,” with Amanda echoing that there are “so many layers to the healing process.” Kimberly felt it important to remind herself that “you’re probably not going to see the seeds that you plant develop a lot of times.” Another important aspect of healing trauma, mentioned by half of the sample, was understanding clients’ stages of change. Stacy shared that one of her clients “went back to her hometown and relapsed immediately. And that’s also a hard thing to deal with—to know that I felt like we had some good sessions . . . and then it’s, ‘Wait a minute. You went back to the relapse [sex trafficking].’” Cristina noted that “especially [when they’re] first out and they’re not quite sure, that pre-contemplation if they want to leave or stay” was very important.

Another important aspect of their work included boundaries and self-care. All participants acknowledged that at some point in their careers, it was challenging to practice healthy boundaries. Cassandra acknowledged the following when working with individuals forced into sexual acts, “I wish I could take all the ladies I’ve ever worked [with], that have danced on stripper poles for money, unwillingly, and just like put clothes on them and wrap them up and hug them.” She added,

[It] can get really tricky when we start answering our phone because it’s an emergency all the time . . . and it’ll wear you out, your batteries will wear out, and you’ll end up having this dual relationship that will end up hurting her because . . . you’re not her friend.

It was helpful for Cassandra to remind herself that she was not the client’s parent. Rather, she shared, “when I hear things like that, I have to remind them that this is my job, this is what I do for a living.” Implementing healthy professional boundaries reduced burnout and facilitated self-care. Participants highlighted activities such as meditating, doing yoga, or taking the occasional day off. The counselors heeded that self-care also included managing their caseload to limit emotionally heavy clients or seeing a personal counselor themselves, as Cassandra and Amanda respectively noted. Amanda said, “you definitely have to secure your oxygen before you can secure other people’s.”

Understanding Sex Trafficking and Survivors
     All participants explained that working with this population required them “to understand what sex trafficking is and . . . the many different ways that it looks,” as stated by John. He elaborated that “it takes many different forms and shapes,” some of which may not be immediately recognized as trafficking. Participants agreed that sex trafficking can often be much more discreet than one might anticipate. Tiffany commented on media portrayals like the film Taken, stating that the real experience is often much less dramatic: “Listening to their stories, it’s very, very subtle . . . like, if you do this then I’ll pay for your college tuition . . . and then from there it gets bigger.” Similarly, Cassandra noted that sex trafficking “can be, like, a bunch of underaged females, thrown in the back of a truck and trafficked across the United States” or people that “have their own residences, that don’t actually live with the trafficker, or they live with a family member that’s trafficking them.”

Counselors learned that although anyone can be trafficked, some populations are more vulnerable. According to Fen, these populations include clients with cognitive disabilities, immigrants, emotional abuse survivors, clients with PTSD, and clients with addictions. Other populations mentioned included the LGBTQ+ population, people recently released from jail/juvenile detention centers, college students with debt, and people in financial need.

The participants’ work also required them to learn how clients were recruited and what kept them from leaving sex trafficking. John and Amanda noted that many survivors knew their traffickers or were introduced to them by family, friends, or a romantic partner. Ana explained that traffickers may kidnap people from big sporting events or from opposing gang(s) or may train survivors to recruit and groom for them. She also worked with women recruited online from abroad and trafficked once they arrived in the United States. Counselors also learned about the numerous tactics used by traffickers, including the trauma bond, coercion, and control. John noted that traffickers often use manipulation: “The common theme was ‘If you do this, you’d really be helping me out. You wanna see me be okay?’ or ‘You don’t want me to go to jail, do you?’” Cassandra reported working with a client whose parents used “an odd twist on Christianity” and the principle of “respect your elders” to traffic her. Other tactics mentioned were threats of violence against survivors and their families, branding or tattooing survivors, stalking, taking survivors’ IDs, gaslighting, and fear. Cassandra also observed that trafficking was “so alluring . . . there’s a lot of money in that . . . so much about leaving sex trafficking is starting from zero and creating something new.” Amanda recalled a client who “was very upscale and so they lived kind of a lavish lifestyle, and I could see and understand, really emphasize the struggle to like give that up,” particularly when they were worried about providing for their families. Factors that forced individuals into sex trafficking were multilayered. Amanda continued, “so many other facets and like layers to this. It’s like an onion.”

As a result, counselors learned about the overall impact of sex trafficking on survivors’ mindsets, behaviors, and presenting symptomology. As noted by Kimberly, sex trafficking impacted every aspect of survivors’ lives. Tiffany noticed that many of her clients were initially very fragile and mistrusting of everyone, while Cristina and Stacy shared that it was common for their clients to display guarded and closed-off body language. John’s work taught him that sex trafficking “affects [clients] in terms of intimacy and trust, and that trickles into their relationships, whether it’s with family, roommates, or romantic partners.” The counselors’ work with sex trafficking survivors included clients with an array of presenting concerns. Cassandra observed clients with complex PTSD, substance use issues, self-harm behaviors, suicidal ideation, self-hatred, self-blame, feelings of insecurity, an inability to trust, and eating disorders. Ana also noted that clients presented with anxiety, depression, paranoia, and physical concerns such as sexually transmitted diseases (STDs) and sleep problems.

Counselor Skills: “Creating a Safe Space to Dive Into Work”
     All participants recognized that because of the nature of their work and their clients, they needed to “create a safe space to dive into work,” as stated by Tiffany. To do so, they needed to build skills in two main categories: (a) assessment and ensuring safety and (b) processing trauma. Amanda explained, “I think all of that stuff [assessment and ensuring safety] really has to come first before we can do any really heavy work and therapy. . . They have to be stable before they can really dig into whatever they want to dig into.” Although this separation provides clarity, counselors’ experiences were also more fluid, at times requiring them to use skills particular to ensuring safety while processing trauma and vice versa.

Assessment and Ensuring Safety
     All counselors’ experiences of assessment and ensuring safety consisted of effectively engaging with their clients during the intake interview, assessing risk, applying crisis skills, and formulating personalized treatment plans. Based on her experiences, Cristina spoke about the importance of building rapport during that initial interview: “When I do our initial assessment with them . . . I have the assessment, but I’m having a conversation with them.” She also learned to discuss confidentiality and mandated reporting with her clients to explain her role as the counselor while also giving them a choice: “I tell them straight out, like, ‘Hey, you tell me this, I have to report it, I have to call law enforcement . . . so how do you want to do it?’” Cassandra found that obtaining a thorough history of the client was a critical part of the process:  

When addressing trauma, I don’t just go back to when the trafficking started. I go all the way back, make sure that I have that thorough history, because 99 times out of a 100, from my experience, that was not the first trauma that person experienced.

     Seven participants spoke about learning the signs of sex trafficking and knowing what questions to ask to obtain more information and determine a person’s exposure to sex trafficking. Amanda explained, “I don’t think I’ve ever had somebody start off within an intake session be, like, ‘Hiya, so I was trafficked.’” Participants learned to ask about phone use and the number of phones owned, the extent of drug use, sexually transmitted diseases, wanted and unwanted pregnancies, boyfriends and their ages, and sexual behaviors such as the use of a condom. When assessing, Alejandra learned to “ask questions that minimize you coming across as being shaming or judging.” At the same time, some counselors spoke about the lack of sex trafficking assessments that could facilitate this part of their work. Alejandra explained that she “did an assessment at work yesterday, and there, there are no questions about sex trafficking. . . . There are questions about abuse, but it is inferring more [about] sexual abuse, physical abuse, emotional abuse versus sex trafficking.” Fen echoed this sentiment by wishing there was a more rigorous psychosocial interview that assessed risks associated with sex trafficking because “at times people do hide and at times people don’t disclose.”

All counselors agreed that a significant aspect of ensuring safety for their clients was collaborating with clients on safety plans. Counselors took the time to develop a “well thought out” safety plan with their clients, as stated by Alejandra. Stacy explained how she helped the client brainstorm ways to feel safer, including leaving town for a while or taking steps to “create a new account, changing her look a little bit . . . getting [a] new phone number.” Collaboration was not only utilized to respect clients’ autonomy but also to instill hope—“Hope that you know that you have a future,” stated Cristina. Ana elaborated, “seeing what they want for themselves and their lives, like, where do you want to go with your life . . . if you didn’t have this going on, you know, what is it you would like to do for yourself?”

Processing Trauma
     To process trauma, all counselors listed skills, interventions, and therapies they found helpful with this population. Utilizing foundational skills (e.g., reflection, open-ended questions, appropriate self-disclosure) to build rapport was the most referenced code in this section, addressed by all participants. Cristina saw the benefit of learning how “to connect very quickly.” Stacy added, “I would definitely start relying a lot more on the rapport when I work with trauma.” Counselors also found it helpful to have a toolbox that included creative approaches and interventions that helped clients reclaim power, develop a support system, improve self-esteem, build and discover resiliency, and utilize the client’s strengths. Psychoeducation, mentioned by nine participants, included teaching their clients about sex trafficking because as John explained, “clients don’t always know that they are being trafficked.” Psychoeducation of sex trafficking requires explaining fraud, force, and manipulation. Kimberly explained how a client did not think she was trafficked because her partner did not have her “locked in a closet. I don’t got chains around me. I’m not his slave . . . I get up and get myself dressed. I go out there and meet these guys . . . I cooperate when he’s taking pictures of me.” To help her client reevaluate her situation, Kimberly utilized motivational interviewing–based questions such as “Would you let your sister do this?” or “What would be the benefits of leaving your situation?”

Although most counselors felt that an integrative approach to counseling worked best with sex trafficking clients, the therapies most mentioned included dialectical behavioral therapy, narrative therapy, and eye movement desensitization and reprocessing therapy. Counselors recommended individual treatment to process trauma, although four participants also mentioned family and group counseling. Fen found family therapy helpful “if the family wants to get involved in the practice” and “if there are family members who are ready to support them and come with them and who are aware of this.” Other participants mentioned the benefits of providing group counseling for sex trafficking survivors. Cassandra recalled how members of a support group she facilitated “connect with each other, they know that they’re not alone, they give each other honest feedback. . . . It has been super empowering.” Yet Alejandra, Fen, and Tiffany found that group counseling may not be well suited for all clients. “Group therapy doesn’t work really well because you know every survivor is different, and they don’t want to open up in front of others until they have worked through the process for a long time,” explained Fen.

Because of the nature of their work, counselors recognized that an essential skill to processing trauma was learning how to manage countertransference. Cristina spoke about how as “clinicians, we want to save all of them.” For this reason, Kimberly recognized that it was important for her to understand her attachment style. Cassandra recalled nights when she would go home and “worry about [if] I am going to see this client again.” Ana left sessions “shaking sometimes from those places . . . ’cause the stories I would hear.” Stacy highlighted that it was also difficult at times to manage the lies. She explained, “I was a little frustrated because I knew that she was hiding things . . . obviously it just wasn’t that time and that’s okay.” As a result, counselors found it essential to process their emotions. Kimberly explained that “if you haven’t emptied your cup of all the sad, mad, bad before you come into that office with them . . . you’re going to flip your lid whether it’s in front of them or behind closed doors.” 

Counselor Attitudes: “Being Able to Listen to the Client’s Story”
     All participant interviews illuminated thought patterns and beliefs they needed “to listen to the client’s story,” as stated by John. Counselors learned to personify certain attitudes by (a) valuing empathy and validation and (b) embodying a sense of safety.

Valuing Empathy and Validation
     All participants highlighted the importance of embracing a philosophy of empathy and validation in their work with clients by being warm, genuine, open-minded, patient, and nonjudgmental. Participant interviews described various mechanisms to embody these attitudes. For instance, a consistent approach they took was to respect and empower the clients’ choices and, ultimately, believe in and provide client autonomy through supportive and nonjudgmental means. Ana emphasized, “I think that’s huge for those whose choices were taken away. . . . It’s offering them a choice, and I think that’s very empowering for them.” Fen echoed this message stating, “You can’t push—you can definitely motivate—but you cannot just push.” Kimberly learned to be patient: “You’ll end up getting there eventually, just take your time. . . . You have to build that rapport and trust.” Cassandra stated, “Another thing I would say is don’t make any assumptions. . . . Everybody’s experiences, although there are similarities, every experience is so different.” Cristina described the shock value of hearing survivors’ stories and how essential it was for her to remain nonjudgmental and aware of her biases. Amanda embodied “those Rogerian qualities, like that open-mindedness, empathy, warmth, genuineness, authenticity—those things are all really important to utilize when meeting with that population, or any population.” Cristina provided an example of how she conveyed this to a client by saying, “I’m here if you need me. . . . There’s no judgment happening, I’m just glad you’re here.”

Counselors also shared a philosophy that validated clients’ experiences. Fen believed in “just making clients feel normal,” while Cassandra noted how helpful it was for her to approach clients’ behaviors as “normal reactions to abnormal situations.” An important attitude communicated by John was that “they are survivors.” Even though others and possibly even the client themselves might use the word victim, he found it helpful to have “the conversation about being a survivor versus a victim.” Tiffany further explained, “I’ve noticed just in working with sex trafficking survivors . . . it seems very hard for them to say the word ‘abuse’ or view themselves as anything other than a victim.” She found value in seeing the client as “a survivor” and teaching this perspective to the client.

Embodying a Sense of Safety
     All participants embraced attitudes that created and maintained a safe environment for their clients. Fen explained that as the counselor, “you’re the only safety net for that person” who provides safety and trust. Cristina reflected on a client who was still in “the life” and returned for help and services when needed. She stated, “she knows that I’m a safe person” and “this [shelter name] is her home, this is where she felt safe. But [she] knew she couldn’t get out of this life yet because she wasn’t ready to.” Fen explained that “there is shame, there is guilt, there is fear, and apprehension of being caught . . . so, one has to make them feel safe.” Some participants communicated and provided safety by creating a “homier and safer” office space or by buying a client’s favorite snacks and beverages, as described by Cassandra. Alejandra spoke of establishing “an environment where it’s safe to talk about taboo subjects” such as “having been a mule or whatever they did, you know, whatever sexual acts.”

Six of the participants also spoke of attitudes that promoted consistency and predictability. Kimberly stated, “That’s something they’ve never had in their life; you know, so while you’re doing all this other stuff, be consistent.” Several participants noted how difficult it was for their clients to have continuity with counselors. Kimberly shared:

Counseling someone who’s had this kind of trauma takes a long time . . . once you leave and can’t continue that counseling process, the likelihood of them going back to the counseling is very slim to none. . . . Even though they were resistant to building that rapport with you at the same time, deep down inside they’re connecting with you.

     Similarly, a few participants learned to be consistent in their messages shared with clients and accessibility to clients. For instance, Stacy spoke of the need for congruency between actions and words when working with these individuals: “Trust is such a fleeting word . . . it has to be action, sometimes, speaks louder than the words.”

Counselor Action: “More Than Just a Counselor”
     All participants realized that working with this population required them to reevaluate their role as the counselor. They learned that clients required “more than just a counselor,” as stated by Kimberly. Therefore, the fourth theme elucidated actions that counselors found necessary to help clients recover from their experiences. We categorized counselor action into two subthemes: (a) client advocacy and (b) engaging with social work/workers.

Client Advocacy
     Over half of our participants spoke about the importance of advocating for clients. Cristina talked about how some clients did not have a caseworker and needed someone “that’s in their corner.” Counselors spoke about specific needs they advocated on behalf of clients in the life or in recovery. Kimberly spoke about advocating for prison reform, particularly for minority women who went to prison for some of the things they got involved in while being trafficked. Cristina advocated for “easier access to get into drug treatment.” She explained that this was necessary because certain insurances did not pay for certain drug treatments, or it would take too long to get clients into treatment. Although clients would sometimes agree to treatment, it would take several days “to get everything going. . . . by then the kids change their minds, or they run. . . .The obstacles shouldn’t be that hard.” Other forms of advocacy focused on working with and educating police officers to best work with this population. Tiffany explained how many women didn’t trust law enforcement. She believed it was crucial to bridge these services because law enforcement could “get them out of that lifestyle, but then on the other hand, they’re very much like, ‘Don’t trust them.’” Stacy also spoke about advocating for shelters specific to sex trafficking. She remembered a client who visited a shelter once a month and loved it because “she felt safe there versus just, like, a domestic violence clinic . . . they had the awareness of sex trafficking versus just, like, you know, an overnight shelter type of place.”

Participants also taught clients how to advocate for themselves while also respecting their choices. Stacy explained, “It’s not my job to fix what they’re going through, but it is my job to be as supportive as I can.” She understood that she needed to “advocate for them but also having the respect that if they don’t want me to advocate for them, then that’s the place that they’re at too.” Stacy also clarified that at times she does not “really know exactly 100% how I would want to advocate” for clients who had been trafficked. Yet as she continued to reflect, she realized her desire to “seek out more education about it because I do think that it needs to be navigated in a specific way.”

Engaging With Social Work/Workers
     The call for advocacy led all counselors to speak about how their work required them to expand their roles to connect clients to resources and collaborate with social workers. Kimberly explained that this population requires “more than just a counselor while they’re in session . . . you’ve really got to start with building a community around them before you get into the deep trauma work.” Counselors provided resources to obtain transportation, financial assistance, government assistance, their GED or college degree, food, employment, stable housing, legal support, childcare, hygiene products, substance treatment, and medical care. Amanda explained that this population requires that their basic-level needs be met to help them feel like they “can function in society and be comfortable,” and Kimberly elaborated:

As a counselor, I used to have a huge list of resources that I could give them, but they also needed guidance from outside of the counseling office. . . . I have, like, eight people with one survivor, that’s how much it took us ’cause it’s so much work for one person. You’re talking about every aspect, everything that you learned as a child growing up. . . . If you want counseling to be successful, they have to have that outside component to help them . . . a counselor can’t do all of that.

     Ana partnered up with organizations already doing this work. She particularly spoke about an organization that not only focused on “educating people but also helping these women with resources.” She added that “the residential places they were able to stay in, they were able to finish their education and get an education there, and they also helped them with finding jobs, which was really important for them, too.” She explained that this was particularly important because many of the women she worked with had a violent criminal history. Many company insurances refused to hire women with criminal records, preventing their clients from a second chance at improving their lives. However, John learned to support clients with resources. “I don’t think it’s sufficient to just say ‘Here you go, here’s the resource guide. They have lots of options in there. Good luck.’ . . . Our job doesn’t end with giving the resources,” he explained.

An important point to make is that although some counselors spoke about collaborating with social workers, it seemed that most believe their work resembled “a little more of that, like, case management–type stuff to make sure that they have the resources if and when they want out,” added Cassandra. Kimberly elaborated, “You’re the one that’s helping to get them to [a] place where they can have a relatively stable life . . . but without the resources that come alongside that, they’re gonna go nowhere, [they’re] going to hit a wall every time.”

Discussion

We sought to understand counselors’ experiences working with sex trafficking survivors through a phenomenological analysis. The participants in our study needed to understand and address the different aspects of trauma. Because of clients’ traumatic experiences that resulted in psychological injuries (Cole et al., 2016; Grosso et al., 2018; Lutnik, 2016; Muftić & Finn, 2013; O’Brien et al., 2017), counselors benefited from respecting the process of healing, addressing stages of change, and building a safe and trusting relationship. Counselors overall possessed knowledge of the development of post-trauma responses over time. They knew what to look for and how to best treat traumatic symptoms that permeated all aspects of their client’s lives, particularly sex trafficking survivors’ ability to trust others. Counselors believed that having a trauma-informed approach could reduce instances of re-victimization. Counselors also recognized the importance of self-awareness such as assessment of personal trauma, self-care, restorative practice, and biases regarding how youth are trafficked and by whom.

Yet, our findings demonstrate that working with sex trafficking survivors requires additional competencies as illustrated in previous research (Interiano-Shiverdecker et al., 2023). The participants discussed the need to become educated in recognizing the signs of sex trafficking, vulnerable populations, and the processes by which traffickers force people into sex trafficking to obtain a deeper understanding of the client’s worldview and provide appropriate support (Interiano-Shiverdecker et al., 2023). Participants addressed components—namely force, fraud, coercion, exploitation, power, grooming, and solicitation—commonly used in sex trafficking literature (Bruhns et al., 2018). When asked about the nature of their work, their focus naturally divided into sections that focused on assessing risk and safety planning, processing trauma, and helping the client re-establish their life and their identity. Our findings align with CACREP (2015) recommendations for clinical crisis skills and knowledge while also elucidating their application to sex trafficking survivors. Participants learned to assess for specific sex trafficking signs (e.g., phone usage, boyfriends and their ages, sexual behaviors) and to ask questions that differentiated sex trafficking from other forms of abuse.

Counselors must also understand the differences between sex work (i.e., the voluntary exchange of sexual services for compensation) and sex trafficking (i.e., subjection to the exchange of sexual services due to force, fraud, or coercion or from any person under the age of 18). As Ana shared, most counselors felt that the notion to detect was on their end “because I don’t always think it’s the responsibility of the client to be able to say ‘Hey, I’ve been trafficked.’” Thus, participants indicated that possessing these competencies could help increase the identification of sex trafficking. As such, some counselors may desire more guidance on specific sex trafficking assessments, which scholars have previously noted (Interiano-Shiverdecker et al., 2022; Romero et al., 2021). A content analysis on sex trafficking instruments (Interiano-Shiverdecker et al., 2022) illustrated the importance of asking specific questions to assess for control, confinement, threat, and isolation, as these are the main indicators of sex trafficking. Example items included: “Have you ever felt you could not leave the place where you worked [or did other activities]?” (confinement; Simich et al., 2014, p. 20); “Are you kept from contacting your friends and/or family whenever you would like?” (isolation; Mumma et al., 2017, p. 619); “Do you have to ask permission to eat, sleep, use the bathroom, or go to the doctor?” (control; Mumma et al., 2017, p. 619); and “Has anyone threatened your family?” (threat; Mumma et al., 2017, p. 619).

Moreover, for some sex trafficking victims, the relationship with their traffickers represented an affirming, reliable, and secure relationship in their lives, later used to coerce or force them into sexual, violent, or illegal behavior. Therefore, participants realized that processing trauma would require attitudes and skills that provided emotional safety, patience, and a nonjudgmental process. Survivors’ lack of choice throughout their sex trafficking experience fomented counselors’ abilities to empower clients over their bodies, boundaries, and choices, and help clients reintegrate into society (Interiano-Shiverdecker et al., 2023; Thompson & Haley, 2018). Participants seemed to emphasize that without all the elements mentioned, clients might not disclose their situation or trust the counselor enough to open up, and they might even terminate counseling abruptly.

This last point is connected to our fourth finding, counselor action. Aligned with the Multicultural and Social Justice Counseling Competencies (Ratts et al., 2016), the participants in our study recognized the need to engage in work that advocated for clients within and outside of the session. Despite their dedicated work with clients to process the emotional repercussions of sex trafficking and rebuild their lives, their efforts did not seem enough to support clients in their recovery. So much of what ailed their clients fell on systemic or external forces (e.g., poverty, employment, lack of resources). Although that existed outside of the counselor’s role and verged into another profession, our participants embraced these responsibilities or connected with other professionals. They believed that otherwise, clients would not succeed in their recovery. Our findings present an important reminder that sex trafficking, a modern form of human slavery, is an act of social injustice affecting individuals vulnerable to historical and systemic oppression.

Implications
     Our themes add to the existing research with implications for counseling practice, supervision, and education. Scholars (Romero et al., 2021; Thompson & Haley, 2018) have identified counselors as first-hand responders to the early detection and prevention of sex trafficking. Although each trafficking scenario is unique, counselors need to refer to sex trafficking indicators, recruitment and grooming tactics, and manipulative dynamics that prevent individuals from disclosing or leaving sex trafficking. It is important for counselors to dispel common myths of sex trafficking and understand that sex trafficking may appear differently than one may expect. Amanda alluded to clients who defined their experience as a “lavish lifestyle” and were lured by the financial benefits of sex trafficking. We caution counselors not to misinterpret sex trafficking as a “lifestyle,” as this implies choice. There may be a myriad of invisible factors contributing to their circumstances such as trauma bonding and financial instability.

Participants agreed that an integrative approach with interventions that addressed complex trauma (e.g., dialectical behavior therapy, eye movement desensitization and reprocessing therapy) worked best when working with sex trafficking. We encourage counselors to not only become familiar with such modalities but also to conceptualize any treatment modality through a trauma-focused lens that considers how sex trafficking impacts all aspects of a client’s life and how they will interact in session. Participant narratives indicated that clients could present with defiant behaviors, distrust, angry or irritable mood, and refusal to comply with treatment. These themes underscore the importance of a counselor’s ability to create safe, trusting, and empathic relationships that allow the client to disclose risk and eventually process trauma. Counselors should also integrate a strong rapport with sex trafficking clients by demonstrating unconditional positive regard, authenticity, and empathy with any treatment modality chosen. Although counselors establish a strong therapeutic relationship, they can integrate other counseling goals, including psychoeducation, assessing for risk, supporting clients through the stages of personal change, and helping the client rebuild and reintegrate into society. Based on the nature of their work, managing countertransference and self-care represents an essential instrument to maintain balance while engaging in emotionally draining clinical work. We encourage counselors to seek supervision, connect with colleagues, and practice regular self-care routines to avoid experiencing burnout, secondary trauma, and countertransference. Additionally, counselors should connect clients to services that provide basic needs (e.g., safe and stable housing, food). When clients lack basic physiological needs, they may struggle to focus on higher-order needs such as developing a safety plan or emotion regulation. Counselors can engage in legislative advocacy by writing letters to judges, sharing clinical experiences with senators, and providing training on sex trafficking victim identification and treatment. It is important for counselors to build constituency groups with education, governmental task forces, and legislators to lobby for bills that benefit clients, as sex trafficking exists in an ecosystem of community and social contexts (Farrell & Barrio Minton, 2019). Our findings also underscore the limitations of intake interviews when assessing for sex trafficking risk. Although identification and screening tools exist (Interiano-Shiverdecker et al., 2022; Romero et al., 2021), counselors are not always in a setting where a formal assessment is appropriate or accessible.

We encourage educators and supervisors to emphasize the value of informal assessment methods with counselors-in-training. Counselor knowledge of signs, symptoms, and questions to ask during an intake can improve identification efforts. Our findings also hold some implications for training beyond counselor education. Because of the complexities of working with trauma and sex trafficking, counselors intending to work with this population should seek out specialized training. For instance, they may review conference programs for trauma or sex trafficking–specific education sessions. At the same time, counseling programs should evaluate their preparation for counselors to work with sex trafficking. Requiring a trauma course, including content on sex trafficking and complex trauma throughout the curriculum (e.g., trauma, grief, addiction counseling courses), inviting guest speakers, and providing training opportunities and workshops for students and community counselors are all suggestions to ensure that counselors obtain the necessary knowledge and skills to work with this population. We believe that more training opportunities can minimize any possible misunderstanding of sex trafficking, expectations on clients to disclose, and re-victimization of clients that leads to early termination of counseling.

Limitations and Future Directions
     The nature of our sample holds some limitations for the interpretation and application of the themes from this study. We collected data from single data sources (i.e., individual interviews); additional interview sources (e.g., focus groups) may have contributed more information. Moreover, lack of racial and gender diversity was a limitation in this study because most participants identified as White and female. We noticed that participants did not discuss racial and gender differences in clients’ experiences of sex trafficking. This result could have originated from our interview protocol that sought to gain an overall understanding of sex trafficking experiences and therefore did not request this information. Participants’ demographic profiles may have also provided a limited perspective of the experiences of Black, Indigenous, and/or people of color. We also did not require CACREP accreditation or specific years of practice as part of our inclusion criteria. Although all our participants were licensed professional counselors, they had different degrees in mental health, a variety of clinical practice, and did not all graduate from CACREP-accredited programs. During our interviews, we did not define sex trafficking to the participants and engaged in open-ended questions that inquired about their experiences. Participants’ responses are based on their definition of sex trafficking, which can vary and might not be accurately distinguishable from sex work. As is the case with all qualitative research, counselors and scholars should consider the transferability of these findings to other client populations and with counselors. For example, the findings of this study can be applicable to professional school counselors, but the recruitment of school counselors as participants would have provided greater insight into the roles and responsibilities of counselors in schools. Furthermore, we did not include client perspectives in this study; therefore, even though our participants’ perspectives when working with sex trafficking survivors is very insightful, they may not have an accurate representation of clients’ experiences in session.

Based on these limitations, we recommend scholars explore individual and external factors that can impact counselors’ work with sex trafficking survivors. For example, we did not explore within-group differences (e.g., race, gender, sexual orientation, religion) between counselors and cross-cultural interactions between clients and counselors. These factors are important to consider and reflect on when building trust and a sense of safety for the client, particularly when considering current conversations around racial tension in the United States. A more in-depth analysis of these considerations could facilitate a better understanding of how multicultural traits play a role in counselors’ experiences when working with sex trafficking survivors. Participants’ emphasis on the need for specialized knowledge and skills to work with sex trafficking also warrants research on evidence-based interventions for sex trafficking survivors. Moreover, an examination of the client’s experiences is necessary to garner a holistic picture of the impact of sex trafficking on the client’s healing and counseling process. We also believe that researchers should consider external factors that might impact counselors’ experiences when working with sex trafficking. Considering participants’ discussion of advocacy and engaging with social work/workers, it seems necessary to consider sociopolitical and institutional elements that either hinder or support clients’ ability to leave sex trafficking and obtain access to services that allow them to heal and flourish. As such, counselors working with sex trafficking survivors must consider specific training that allows them to assess for risk, process the emotional ramifications of sex trafficking, and rebuild their lives.

 

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

References 

American School Counselor Association. (2022). ASCA ethical standards for school counselors.
https://www.schoolcounselor.org/getmedia/44f30280-ffe8-4b41-9ad8-f15909c3d164/EthicalStandards.pdf

Browne-James, L., Litam, S. D. A., & McRae, L. (2021). Child sex trafficking: Strategies for identification, counseling, and advocacy. International Journal for the Advancement of Counselling, 43, 113–125.
https://doi.org/10.1007/s10447-020-09420-y

Bruhns, M. E., del Prado, A., Slezakova, J., Lapinski, A. J., Li, T., & Pizer, B. (2018). Survivors’ perspectives on recovery from commercial sexual exploitation beginning in childhood. The Counseling Psychologist, 46(4), 413–455. https://doi.org/10.1177/0011000018777544

Burt, I. (2019). Modern-day slavery in the U.S.: Human trafficking and counselor awareness. International Journal for the Advancement of Counselling, 41, 187–200. https://doi.org/10.1007/s10447-018-9366-7

Cole, J., Sprang, G., Lee, R., & Cohen, J. (2016). The trauma of commercial sexual exploitation of youth: A comparison of CSE victims to sexual abuse victims in a clinical sample. Journal of Interpersonal Violence, 31(1), 122–146. https://doi.org/10.1177/0886260514555133

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

Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). SAGE.

Farrell, I. C., & Barrio Minton, C. A. (2019). Advocacy among counseling leaders: The three-tiered legislative professional advocacy model. Journal of Counselor Leadership and Advocacy, 6(2), 144–159. https://doi.org/10.1080/2326716X.2019.1644254

Franchino-Olsen, H. (2019). Vulnerabilities relevant for commercial sexual exploitation of children/domestic minor sex trafficking: A systematic review of risk factors. Trauma, Violence & Abuse, 22(1), 99–111. https://doi.org/10.1177/1524838018821956

Grosso, A., Busch, S., Mothopeng, T., Sweitzer, S., Nkonyana, J., Mpooa, N., Taruberekera, T., & Baral, S. (2018). HIV risks and needs related to the sustainable development goals among female sex workers who were commercially sexually exploited as children in Lesotho. Journal of the International AIDS Society, 21(S1), e25042. https://doi.org/10.1002/jia2.25042

Hays, D. G., & Singh, A. A. (2012). Qualitative inquiry in clinical and educational settings. Guilford.

Interiano-Shiverdecker, C. G., Romero, D. E., Anderson, A., & Castellon, N. E. (2022). A content analysis of sex trafficking instruments. International Journal for the Advancement of Counselling, 44, 373–394. https://doi.org/10.1007/s10447-021-09463-9

Interiano-Shiverdecker, C. G., Romero, D. E., & Elliot, J. (2023). Development of child sex trafficking counseling competencies in the United States: A Delphi study. Journal of Interpersonal Violence, 38(1–2), 1397–1423. https://doi.org/10.1177/08862605221090569

International Labour Organization. (2017). Global estimates of modern slavery: Forced labour and forced marriage. https://www.ilo.org/global/topics/forced-labour/publications/WCMS_854733/lang–en/index.htm

Johnson, B. C. (2020). Featured counter-trafficking program: Trauma recovery for victims of sex trafficking. Child Abuse & Neglect, 100, 104–153. https://doi.org/10.1016/j.chiabu.2019.104153

Kenny, M. C., Helpingstine, C. E., Harrington, M. C., & McEachern, A. G. (2018). A comprehensive group approach for commercially sexually exploited girls. The Journal for Specialists in Group Work, 43(4), 376–398. https://doi.org/10.1080/01933922.2018.1484540

Litam, S. D. A. (2017). Human sex trafficking in America: What counselors need to know. The Professional Counselor, 7(1), 45–61. https://doi.org/10.15241/sdal.7.1.45

Litam, S. D. A. (2019). She’s just a prostitute: The effects of labels on counselor attitudes, empathy, and rape myth acceptance. The Professional Counselor, 9(4), 396–415. https://doi.org/10.15241/sdal.9.4.396

Litam, S. D. A., & Lam, E. T. C. (2020). Sex trafficking beliefs in counselors: Establishing the need for human trafficking training in counselor education programs. International Journal for the Advancement of Counselling, 43(1), 1–18. https://doi.org/10.1007/s10447-020-09408-8

Lutnik, A. (2016). Domestic minor sex trafficking: Beyond victims and villains. Columbia University Press.

Moustakas, C. (1994). Phenomenological research methods. SAGE.

Muftić, L. R., & Finn, M. A. (2013). Health outcomes among women trafficked for sex in the United States: A closer look. Journal of Interpersonal Violence, 28(9), 1859–1885. https://doi.org/10.1177/0886260512469102

Mumma, B. E., Scofield, M. E., Mendoza, L. P., Toofan, Y., Youngyunpipatkul, J., & Hernandez, B. (2017). Screening for victims of sex trafficking in the emergency department: A pilot program. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 18(4).
https://doi.org/10.5811/westjem.2017.2.31924

National Human Trafficking Hotline. (n.d.). National statistics. https://humantraffickinghotline.org/states

O’Brien, J., Li, W., Givens, A., & Leibowitz, G. S. (2017). Domestic minor sex trafficking among adjudicated male youth: Prevalence and links to treatment. Children and Youth Services Review, 82, 392–399. https://doi.org/10.1016/j.childyouth.2017.09.026

Oram, S., Abas, M., Bick, D., Boyle, A., French, R., Jakobowitz, S., Khondoker, M., Stanley, N., Trevillion, K., Howard, L., & Zimmerman, C. (2016). Human trafficking and health: A survey of male and female survivors in England. American Journal of Public Health, 106(6), 1073–1078. https://doi.org/10.2105/AJPH.2016.303095

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

Romero, D. E., Interiano-Shiverdecker, C. G., Castellon, N. E., & Strentzsch, J. (2021). A review of child sex trafficking instruments. Journal of Child and Adolescent Counseling, 7(1), 56–69. https://doi.org/10.1080/23727810.2020.1835421

Schmidt, C., Lenz, A. S., & Oliver, M. (2022). Effectiveness of TF-CBT with sex trafficking victims in a secure post-adjudication facility. Journal of Counseling & Development, 100(4), 1–13. https://doi.org/10.1002/jcad/12438

Simich, L., Goyen, L., Powell, A., & Berberich, K. (2014). Out of the shadows: A tool for the identification of victims of human trafficking. Vera Institute of Justice. https://www.vera.org/publications/out-of-the-shadows-identification-of-victims-of-human-trafficking

Thompson, J., & Haley, M. (2018). Human trafficking: Preparing counselors to work with survivors. International Journal for the Advancement of Counselling, 40(3), 298–309. https://doi.org/10.1007/s10447-018-9327-1

U.S. Department of State. (2021). Trafficking of persons report. https://www.state.gov/wp-content/uploads/2021/09/TIPR-GPA-upload-07222021.pdf

Victims of Trafficking and Violence Protection Act of 2000, Pub. L. No. 106-386, § 103, 114 Stat. 1470.

Wang, X., & Park-Taylor, J. (2021). Therapists’ experiences of counseling foreign-national sex-trafficking survivors in the U.S. and the impact of COVID-19. Traumatology, 27(4), 419–431. https://doi.org/10.1037/trm0000349

Woehler, E., & Akers, L. (2022). Repairing the trauma bonds of sex trafficking victim-survivors with animal-assisted therapy. Journal of Creativity in Mental Health, 17(4), 456–458. https://doi.org/10.1080/15401383.2021.1921646

 

Claudia G. Interiano-Shiverdecker, PhD, LPC-A, is an assistant professor at the University of Texas at San Antonio. Devon E. Romero, PhD, NCC, LPC, is an assistant professor at the University of Texas at San Antonio. Katherine E. McVay, PhD, LPC, is an assistant professor at Texas A&M University–Corpus Christi. Emily Satel is a graduate of the master’s program in clinical mental health counseling at the University of Texas at San Antonio. Kendra Smith is a graduate of the master’s program in clinical mental health counseling at the University of Texas at San Antonio. Correspondence may be addressed to Claudia G. Interiano-Shiverdecker, College of Education and Human Development, One UTSA Circle, San Antonio, TX 78249, claudia.interiano-shiverdecker@utsa.edu.  

 

Appendix

Icebreaker

  • Please tell me a little about yourself, your professional background, and clinical experience.

Counseling

  • What is important for counselors to know when working with sex trafficking survivors?
  • How can counselors best detect when individuals are being sex trafficked or are vulnerable to sex trafficking?
  • How can counselors support individuals while they are being trafficked?
  • How can counselors help individuals leave their traffickers?
  • How can counselors support individuals from returning to their traffickers?
  • What do counselors have to know about supporting sex trafficking survivors after sex trafficking?

Personal Experiences and Mental Health

  • Please share, to the extent that you are comfortable, your experiences with working with sex trafficking survivors.
    • What is the age range in which most of your clients experienced sex trafficking?
  • How have these experiences impacted your clients?
    • Emotionally and mentally?
    • Physically?
    • Relationships with others?
    • Spiritual/religious beliefs?
  • What do you believe has helped them overcome the impact of sex trafficking?
  • What services or resources do you believe were most helpful to them?
  • What is important about your experience that I haven’t asked you and you haven’t had the chance to tell me?

A Qualitative Investigation of Guyanese American Perceptions of Mental Health

May 10, 2023 | Volume 13 - Issue 1

Shainna Ali, John J. S. Harrichand, M. Ann Shillingford, Lea Herbert

Guyana has the highest rate of suicide in the Western Hemisphere. Despite this statistic, a wide gap exists in the literature regarding the exploration of mental wellness in this population. This article shares the first phase in a phenomenological study in which we explored the lived experiences of 30 Guyanese American individuals to understand how mental health is perceived. The analysis of the data revealed that participants initially perceived mental health as negative and then transitioned to a positive perception of mental health. We discuss how these perceptions affect the lived experience of the participants and present recommendations for counselors and counselor educators assisting Guyanese Americans in cultivating mental wellness.

Keywords: Guyanese American, mental health, phenomenological, mental wellness, perceptions

     In 2014, the World Health Organization (WHO) reported Guyana as having the highest suicide rate in the world (44.2 suicides per 100,000 people; global average is 11.4 per 100,000 people). According to World Population Review (2023), within the Western Hemisphere, even after almost 10 years, Guyana remains the country with the highest rate of suicide—a concerning statistic. Responding to the WHO (2014) report, Arora and Persaud (2020) engaged in research to better understand the barriers Guyanese youth experience in relation to mental health help-seeking and suicide. Their research included 17 adult stakeholders (i.e., teachers, administrative staff, community workers) via focus groups, and 40 high school students who engaged in interviews. Arora and Persaud used a grounded theory approach and found the following themes as barriers to mental health help-seeking in Guyanese youth: shame and stigma about mental illness, fear of negative parental response to mental health help-seeking, and limited awareness and negative beliefs about mental health service. They recommended integrating culturally informed suicide prevention programs in schools and communities. In efforts to extend Arora and Persaud’s findings, we sought to further understand how Guyanese Americans define and experience mental health to better serve them in counseling.

Startled by the statistics presented by the WHO (2014) and Arora and Persaud (2020), we were compelled to focus our attention on this unique immigrant subgroup in the United States. It is important to note that between the WHO’s 2014 report and Aurora and Persaud’s research, no other studies related to Guyanese American suicidality are recorded in the literature. However, two studies on Guyanese American mental health emerged by Hosler and Kammer (2018) and Hosler et al. (2019). Our decision to conduct research on the Guyanese American community was further informed by Forte and colleagues’ (2018) review of immigrant literature in the United States, which stated that “immigrants and ethnic minorities may be at a higher risk for suicidal behavior as compared to the general population” (p. 1). Forte et al. found that immigrants, when compared with individuals in their homeland, were at an increased risk of experiencing mental health challenges like depression and other psychotic disorders. Currently, suicide is listed as the 10th leading cause of death overall in the United States (Heron, 2021). More specifically, within ages 10–34 and 35–44, suicide is the second and fourth leading cause of death, respectively. Heron’s (2021) report, referencing the Centers for Disease Control and Prevention (CDC), highlighted that in the United States, death by suicide (47,511) is 2.5 times higher than homicides (19,141). The prevalence of suicide among Guyanese people within and without the United States warranted further exploration of the experiences of this marginalized group.

The Guyanese American Experience

Comparing all countries with a population of at least 750,000 people, Guyana, a Caribbean nation, is said to have “the biggest share of its native-born population—36.4%—living abroad” due to remoteness and limited opportunities within the country to move from a lower to a higher socioeconomic status (Buchholz, 2022, para. 2). It is estimated that the United States is home to approximately 232,000 Guyanese Americans whose ancestry can be traced back to Guyana (United States Census Bureau, 2019), a country in the northeast of South America, bordered by Brazil, Venezuela, and Suriname. Although approximately 50% of all Guyanese immigrants in the United States reside in New York City alone (Indo-Caribbean Alliance, Inc., 2014), Guyanese people can be found across all 50 states and the District of Columbia (Statimetric, 2022). This draw to the United States, an English-speaking nation, might be linked to the fact that Guyana is the only country in South America that recognizes English as its official language (One World Nations Online, n.d.).

Like most immigrants, Guyanese immigrants travel to the United States seeking a better life and opportunities for themselves and their families. However, the process of transplanting can be bittersweet, in that Guyanese immigrants might be forced to relinquish their identity and customs and embrace American customs through assimilation (Arvelo, 2018; Cavalcanti & Schleef, 2001). For many Guyanese immigrants, being caught between leaving their homeland and beginning life in their adoptive home can lead to a cultural clash, resulting in problematic coping mechanisms (e.g., minimizing/hiding mental health challenges, cultural shedding [adopting American identity and losing cultural heritage]; Arvelo, 2018).

As discussed above, suicide in the Guyanese community is unquestionably a serious concern, but the community faces other challenges in the United States as well. For example, Hosler et al. (2019) found a statistically significant association between discrimination experience and major depressive symptoms in a sample of Guyanese Americans. However, Hosler et al. (2019) also found mean scores on the Everyday Discrimination Scale (EDS; Williams et al., 1997) were lower (i.e., less discriminatory experiences in everyday life) for Guyanese Americans when compared to other groups (Black, White, and Hispanic) because Guyanese Americans have a more cohesive interpersonal network. It would appear that Guyanese Americans experience lower everyday discrimination because they operate within interpersonal spaces that are more cohesive, yet their discriminatory experiences are positively associated with depression symptoms, which is a source of concern.

Another area of concern among Guyanese Americans is intimate partner violence (IPV), yet research remains lacking (Baboolal, 2016), leading us to draw directly from Guyanese literature. In Guyana, IPV is one of the most prevalent forms of violence (Parekh et al., 2012). As a country, although Guyana endorses the commitment to gender equality, women are the majority only in the tertiary sector (e.g., education, human services, clerical services, and tourism). Nicolas et al. (2021) stated that “domestic duties, marriage, and child-bearing, particularly for women between the ages of 25–29, have hindered their labor force participation” (p. 147). They documented that 1 in 6 Guyanese women, mostly from rural parts of the country, hold the belief that beating one’s wife is necessary (i.e., husbands are justified in beating their wives, resulting in domestic violence being a relevant mental health issue). In fact, suicide is identified as a public health issue for Guyanese women, who use it as a means of coping “with economic despair, poverty, and hopelessness . . . [and] to escape family turmoil, relationship issues, and domestic violence” (Nicolas et al., 2021, p. 148). However, even with access to mental health services increasing in Guyana, seeking out mental health care is uncommon due to stigma, lack of communication, inadequate financial resources, limited providers, and other barriers related to access (Nicolas et al., 2021). Within the U.S. literature, there remains a dearth of information on the experiences of this group as it relates to suicide and IPV. Most likely, this is a result of racial categorization within the United States, where, based on phenotype and racial composite, individuals are often lumped into one category, such as Black. As important as Guyanese literature on IPV is to inform the work of counselors, we believe it is equally important for us to engage in research regarding IPV and other mental health challenges on Guyanese Americans specifically. Learning about Guyanese Americans’ perceptions of mental health may facilitate closing the gap in the utilization of mental health services, warranting the current investigation.

Recognizing the noticeable research gap related to the mental health experiences of Guyanese Americans, we conducted a thorough review of the literature related to mental health and well-being. Through databases such as PsycINFO, ProQuest Central, Web of Science, MEDLINE, and SocINDEX, using the search terms “Guyanese Americans, Health and Wellbeing, Mental Health of Guyanese Americans, Access to Mental Health,” 54 search results were found. However, only two applicable studies were found to address Guyanese Americans’ mental health specifically (Hosler & Kammer, 2018; Hosler et al., 2019). The other search results were either not research manuscripts (i.e., reflections and newspaper articles) or addressed other constructs specific to the Guyanese people (e.g., family, education). The first study by Hosler and Kammer (2018) focused specifically on the health profiles of Guyanese immigrants in Schenectady, New York. This study was conducted with 1,861 residents between the ages of 18–64 years. Guyanese Americans from Schenectady were mostly from a low socioeconomic status, which resulted in them being less likely to have health insurance coverage, an identified place to receive care, and access to cancer screenings. They were also identified as being more likely to engage in alcohol binge drinking—all conditions of significant concern to us, resulting in the present study. In fact, Hosler and Kammer reported that Guyanese Americans are among the lowest group of those insured in the United States when compared with other minority groups such as Black and Latinx groups. Some researchers believe ethnocentric stereotyping, cultural incompetence by professionals, a lack of steady employment, and poor previous interactions with the health care system are barriers Guyanese immigrants experience when accessing medical and mental health services (Arvelo, 2018; Cheng & Robinson, 2013; Jackson et al., 2007).

The second study of Guyanese immigrants was conducted by Hosler et al. (2019) and explored everyday discrimination experiences and depressive symptoms in relation to urban Black, Hispanic, and White adults. This study included 180 Guyanese Americans (i.e., both citizens by birth and naturalized citizens/immigrants), all 18 years and older, from Schenectady, New York. The researchers found a significant independent association between the EDS score and major depressive symptoms for Guyanese Americans, suggesting that discrimination experiences might be an important social cause for depression within this community. Based on the reported challenges faced by Guyanese Americans, as well as our desire to contribute meaningfully to the extant body of literature on the Guyanese American community, we conducted a phenomenological inquiry. More specifically, we sought to better understand the lived experiences of Guyanese Americans pertaining to mental health (i.e., definitions, beliefs, practices), and how they access and incorporate mental health resources to mitigate the known mental health risks of this population in the United States, in the hopes of creating tailored methods for culturally responsive care.

Method

Because limited mental health research exists on this unique community, the present study, which is part of a larger research endeavor, sought to explore Guyanese Americans’ lived experiences with mental health. To lay the foundation of understanding, the present study focused on Guyanese Americans’ perceptions of mental health. Phenomenology, a constructivist approach, recognizes the existence of multiple realities and provides an understanding of participants’ lived experiences using their own voices (Haskins et al., 2022). We selected transcendental phenomenology (Moustakas, 1994) as the appropriate methodology for answering our research questions, as it is congruent with the counseling profession’s similar objective of understanding the human being. Akin to the practice of counseling, transcendental phenomenology emphasizes methods of the researcher to best set aside the potential clouds caused by bias in an effort to allow the explored phenomenon to surface. Transcendental phenomenology aligns with one of the core professional values in the American Counseling Association’s Code of Ethics (ACA, 2014), that of supporting “the worth, dignity, potential, and uniqueness of people within their social and cultural contexts” (p. 3). It also aligns with Ratts et al.’s (2015) Multicultural and Social Justice Counseling Competencies (MSJCC), specifically understanding the client’s worldview domain. Our focus on Guyanese Americans, an understudied minority group in the United States (Hosler & Kammer, 2018) originating from a country that has been identified as having the world’s highest suicide rate (WHO, 2014), led us to select this method so that we could maintain cognizance of our surroundings, hold respect for the population, and examine participants’ experiences (Haskins et al., 2022; Hays & Singh, 2012; Hays & Wood, 2011).

Participants
     Before participants were recruited for the study, IRB approval was obtained from the university with whom Shainna Ali, M. Ann Shillingford, and Lea Herbert are affiliated. Purposive criterion sampling was used to recruit participants, leading to a sample of adults who self-identified as Guyanese American (i.e., either immigrated to the United States themselves or had at least one parent who was born in Guyana). Recruitment materials were shared with Guyanese Americans using counseling listservs (i.e., ACA–AMCD Connect and CESNET) and social media platforms (i.e., LinkedIn, Facebook, and Instagram). Members of the research team contacted all participants using email to share details regarding the study and the informed consent document, collect demographic data, and schedule individual interviews. According to qualitative research, sample size recommendations range from six to 12 participants (Creswell, 2013; Guest et al., 2006; Onwuegbuzie & Leech, 2007). Hence, we sought to recruit 15–20 participants to account for the possibility of attrition.

Our recruitment efforts yielded 73 individuals who expressed interest in the study, 60 of whom met all inclusion criteria and were initially contacted. Forty-three individuals were unable to complete an individual interview due to scheduling conflicts; hence, we secured a total of 30 participants who completed the study. Of this number, 17 participated in individual interviews and a total of 23 individuals participated in a one-time focus group to further clarify data from the individual interviews. It should be noted that 10 of the 23 focus group participants also participated in the individual interview. Further recruitment was deemed unnecessary, as the data analysis reached saturation with data from the individual interviews and focus group. We present demographic data on all participants who engaged in the study, both individual interviews and the focus group (N = 30), in Table 1.

Table 1

Participant Demographic Data


Note. This table provides a breakdown of the demographic characteristics of Guyanese American participants (N = 30).

 

Data Collection and Analysis
     Participants engaged in a semi-structured interview lasting 30–60 minutes, conducted by Ali and Shillingford. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. The interview protocol consisted of three primary questions, and sub-questions were used to clarify responses: 1) How do you define mental health?; 2) Who in your life has had experiences with mental health?; and 3) What experiences have you had with mental health? Prior to conducting our study, we included in our IRB documentation that data collection of individual interviews would follow saturation guidelines and that a focus group could be used for further data illumination. Following initial data analysis, we found it necessary to conduct a 1-hour follow-up focus group via Zoom to probe deeper into the data and to allow participants to clarify concepts related to emerging themes. Upon the first round of analysis, it was noted that several participants experienced a shift in perceptions regarding mental health. Focus group probes explored whether participants noticed this shift, what may have contributed to this shift, and when the shift occurred.

After all focus group and individual interviews were transcribed, we used guidelines outlined by Moustakas (1994) to analyze the data. First, we immersed ourselves in the data, reviewing each transcript individually. The transcripts were then divided equally among the four researchers, who read through each to become familiar with the data. With each transcript, we identified relevant statements reflecting participants’ lived experiences (horizontalization) as Guyanese Americans within the contexts of mental health beliefs and experiences.

Following this process, we met multiple times to review all transcripts and confer about the textural descriptions. We identified relevant codes, then synthesized the textural descriptions into themes based on commonalities, distilling the meaning expressed by participants. Then we engaged in reduction and elimination via consensus coding. This process included reading and rereading transcripts together, which followed an iterative process of reviewing the text and code, coding, rereading, and recoding, before determining which thematic content was a new horizon or new dimension of the phenomenon.

After all transcripts were analyzed following this reduction process, clustering and thematizing occurred (i.e., thematic content was clustered into core themes based on participant experiences; Hays & Singh, 2012; Moustakas, 1994). We extracted verbatim examples from the transcripts to generate a thematic and visual description of the phenomenon being examined. After completing the initial data analysis, we conducted member checking by sending each participant their individual transcript as well as the written results section. Participants were requested to provide feedback on the accuracy of their transcripts. Additionally, following the focus group and elucidation of themes all participants were offered an opportunity to member check and clarify the degree to which the results aligned with their lived experiences. The participants did not report any errors; however, clarification was offered by one participant.

Trustworthiness and Positionality
     Trustworthiness is a key element of qualitative research in which the research findings accurately reflect the data (Lincoln & Guba, 1985). A critical element of maintaining research credibility is through reflexivity, wherein researchers critically examine procedures employed in relation to power, privilege, and oppression (Hunting, 2014). To safeguard against researcher bias, we worked collaboratively to establish and maintain credibility throughout data collection and analysis processes. Our research team consisted of one Indo-Guyanese American female faculty member, one Afro-Guyanese American female doctoral student, one Black female faculty member, and one Indo-Chinese-Guyanese Canadian male faculty member. All three faculty members belong to CACREP-accredited counselor education programs, and all four researchers have clinical experience working with diverse populations.

To address researcher bias, we engaged in bracketing to minimize the ways in which our experiences influence our approach to research and expectations of the outcomes of the study. Prior to data collection, we discussed our experiences in relation to Guyana, mental health in the Guyanese American community, and our roles as mental health leaders and advocates. We identified our personal experiences, acknowledged our biases, and attempted to bracket while conducting the interviews and focus group. Throughout the data collection and analysis processes, we participated in personal reflection and kept analytic memos documenting our reactions and initial thoughts about the data collected.

Before analyzing the data, we met to confirm analysis procedures, ensuring consistency. We initially analyzed data individually, then determined codes and themes as a team to reduce bias. Throughout the data analysis process, we consulted with each other, addressing questions or concerns related to the data. We also consulted with an outside researcher experienced in qualitative research to obtain critical feedback on the data analysis process and the research findings (Marshall & Rossman, 2006). Our consultant served as an external check of the research methodology and theoretical interpretation of the data.

Findings

The results of the analysis increase understanding of the lived mental health experiences of Guyanese Americans by elucidating perceptions of mental health (Creswell, 2013). All participants shared their beliefs about mental health and the direct and indirect experiences that informed their conceptualization. Three themes surfaced. The first two showed a clear divide in the data: 1) mental health being perceived as negative, stigmatized, elusive, and intimidating; and 2) mental health being perceived as positive, important, helpful, and empowering. It is important to note that these primary themes were not representative of two subsets of participants, and this extracted another theme, which centered on the tendency of participants’ beliefs to transition from negative to positive views of mental health.

The Perception of Mental Health as Negative
     When exploring obstacles, subthemes emerged in which hindrances to mental health were acknowledged to exist across three levels: individual, familial, and sociocultural. In parallel, these three subthemes were echoed in the exploration of factors that participants acknowledged have contributed to their mental wellness. The following section explores the primary themes in detail by highlighting the participants’ voices in describing their lived experiences.

Mental Health Concerns Are a Sign of Weakness
     All participants in the individual interviews shared that they originally believed that mental health developed out of weakness. This belief was often attributed to minimizing remarks from family members. Oftentimes these comments were paired with other suggestions of how to ameliorate symptoms such as praying more, working harder, or contributing to physical health (e.g., drinking tea). Sharon shared:

It was just like, oh no, you just need to read a book or you just need to go and do something and take your mind off of however it is you’re feeling, like there’s no reason for you to be sad, you have a roof over your head and you’re going to school and you’re doing all of these things, it doesn’t matter. There’s no reason for you to be sad or feel any type of way about anything because we provide everything for you.

     Several participants noted that investment in physical wellness was preferable to mental wellness, although physical health was not genuinely prioritized. Participants shared personal and observed maladaptive coping with poor eating habits (i.e., quality and quantity) and excessive substance abuse, namely alcohol. Some participants shared that these tactics were used to manage mental health symptoms or avoidance. Christine shared, “When you’re struggling with things . . . you have nowhere to go to with them except alcohol and the bottom of a rum bottle.” Many participants recognized that coping with alcohol is normalized within the culture. Further, the commonality of these methods normalized consumption and have caused additional issues (e.g., diabetes, heart disease, alcoholism). Arjun noted:

We all have relatives that are kind of stuck on the whole drinking issue. We know a lot of them. They get together with their friends and they “lime,” as we like to call it. They drink in groups and they “gyaff,” they have fun. But it’s a completely different story when they’re by themselves and they’re drinking.

Mental Health Is Taboo
     A general consensus was that all participants in the study once believed that mental health was not important and that mental health problems were shameful and not to be discussed. This consistent trend was one of the reasons that we opted to further understand responses through a focus group. Therefore, a direct probe was offered to the focus group participants to explore if they believed discussing mental health was taboo. When delving deeper into these perceptions, participants noted that these thoughts were informed by the beliefs of others and upheld in the wider cultural paradigm. All participants reported that, generally, mental health should not be talked about in order to save face and be respectful. Because mental health issues were seen to be synonymous with weakness, sharing about mental health was equated with the risk of bringing shame to oneself or to one’s family. For example, Chandra shared that “Guyanese people don’t want a kid that’s broken or a little off.” Hence, if someone opts to discuss their mental illness, it is to be done carefully, or secretly.

Most participants shared that typically, when divulging their symptoms, they went to an elder, often a parent, grandparent, or elder sibling, in an effort to keep concerns within the family system. However, many participants noted being minimized or dismissed when sharing their concerns with family members. Ramona explained her feeling that her family

is really strong about, like, don’t be selfish. And I wonder if they would categorize it under that. Like if you’re taking up too much space or time or whatever, you’re trying to center the attention on you or whatever, so that’s a self-serving thing.

     A generational rule of discourse emerged from the data. Though the tendency was to keep mental health discussions within the family system, it was also atypical for a younger member to address observed issues with an elder. Several participants noted that this hidden guideline kept informed younger generations from being able to utilize their recognition of warning signs to help the given person and the family system. Arjun shared that as he’s gotten older and has learned more about mental health, he has acquired the courage to address the problems he sees with elders, including his uncle:

I said, “Uncle, what’s wrong?” And he said, “No, nothing is wrong.” But he was crying, you could see tears were streaked on his face, but he wouldn’t talk about it—he wouldn’t say anything. It’s not only one time I saw him, it’s multiple times that I’ve seen him when he has been drinking by himself, that he kind of has the same face all the time. Prior to the times that I asked him, I kind of looked at him and I kind of walked away the first couple of times. Because I was kind of like, this is not something that looked like I should butt in, as a child especially. When you’re younger, your parents tell you, “Mind your business.” Or they say, “You’re not an adult, go with the kids.” So . . . the first couple of times I saw him, I kind of avoided it.

Others Are Not To Be Trusted
     Some participants noted that beyond the purpose of family protection, caution to mental health discourse was also due to lack of trust of others. Christine explained: “We had a counseling center on campus, but I was like, ‘Oh, I can’t go talk to anybody,’ because that’s what I was raised with. You don’t talk to strangers about your problems. I had to keep everything inside.” Nevertheless, some families encouraged talking to a religious leader to assist the individual in enhancing devotion and reducing mental health symptoms. Still, regarding professional mental health services, many participants believed, at least at one time, that such services are not helpful, providers are not to be trusted, assistance of that nature is for other (e.g., White) people, and succumbing to that level of desperation is a sign of weakness. When sharing about mistrust in professional mental health assistance, misconceptions and stereotypes surfaced. Ramesh shared:

Oh boy. I have to be honest with you, I feel counseling is, I’ll speak to a shrink and they’ll prescribe drugs to me, like Ritalin or . . . I was like, you know what, I’m better than that. I’m probably totally wrong about it, but that’s just the perception that I have. I’ll be laying on the couch and I’m going to speak into someone and then they’re going to prescribe drugs to me. I don’t want that. I can try to figure this out on myself by talking and trying to do things—positive behavior.

Mental Health Perceived as Positive
     All participants in the individual interviews acknowledged a shift in their perceptions of mental health. Their newfound conceptualization included a holistic view of wellness in which mental wellness was seen as an important component to overall well-being and quality of life. In this newer perception, participants acknowledged the ability to consider more variables influencing mental health than they recognized in the past. For example, many participants noted a link between mind and body, versus the previously held notion that physical health is more important than mental health. A few participants noted that mental health can be influenced by genetics, while some noted that it could be influenced by personality, and others noted that it can be influenced by people and the surrounding environment.

All participants, from both the individual interviews and focus group, concurred that everyone feels mental health effects; furthermore, showing signs of a problem is not attributed to weakness. Moreover, because mental health affects everyone, a widespread belief emerged that we all have the responsibility to foster our mental wellness. Additionally, participants shared several examples of what naturally ensued without investing in strategies for mental health such as challenges with emotional regulation, coping, relationships, and worsening mental health problems.

The Transition Between Negative and Positive Perceptions
     The transition between old and new conceptualizations of mental health was informed by direct and indirect experiences. All participants shared a transition in beliefs in the individual interviews, and this was explored in the focus group for further clarification. Most participants shared that their personal mental health history informed a change in their beliefs. Many of these participants noted the influence of their healing process, most notably seeking professional help. All participants, from both the individual interviews and the focus group, shared at least one example of learning about mental health by observing another person’s experience. For example, Jessie shared, “Unfortunately, I came from a home of domestic violence . . . I was around maybe six, my dad was bipolar . . . [and] he was just a wife beater. That is probably when I can recall [learning] of mental health.” Another example of learning about mental health from others is captured in Reginald’s comment:

[As] an only child . . . my parents took it upon themselves to [teach me]. . . . It wasn’t like, “Okay, sit down. Let me tell you why these things are.” It was just we’ll be talking about somebody else or going over something that happened and then they’ll explain why, but never directly for me. It was always about other people’s kids.

     Many of these individuals emphasized the belief that by paying attention to others, you can learn what is helpful and unhelpful for mental health. Oftentimes this was in their own family; however, extended family and community members were also highlighted. Moreover, a few participants shared their recognition that living with someone who is struggling with their mental health may negatively impact personal wellness (e.g., be triggering). Beyond the family system, some participants noted that exposure to other cultures and perceptions of mental health informed a conceptualization of mental wellness. Seeta shared:

I had friends of other religions or like no religions. And then we would talk about a lot of different things. Like I would ask them questions like, “Oh, so how do things work in your house? Do your parents talk about your God or whatever?” And they’re like, “No.” And I’m like, “So where do your emotions come from?” And they’re like, “Well, you know, we just feel them. Some days I feel angry and some days I feel sad, some days I feel happy.” And I’m just like, “Okay, this is interesting.”

From the quote, it might appear that one’s emotions are in some way connected with God or another higher power; however, this is not something that was observed with other participants of our study. It was more common for participants to share stories of their families using religion as the solution to mental health concerns. For example, Yolanda shared:

My grandmother came when I turned 16 and she kept trying to tell my mom I was showing signs of depression. And my mom was like, “No, she’s like that all the time, like, that’s just how she is.” And my grandma was like, “That’s not normal. You should get her checked out.” And my mom kept saying, “No” and kept denying it. And then my grandma said, “You have to do something.” And then my mom replied, “Oh, I’m going to pray for her.”

     In addition to personal experiences and observations of others, participants noted that improved mental health awareness and education prompted them to think critically about their mental health schemas. Ramesh shared:

My education, I always feel like this is what saved me in the end, because I was able to be around other people to know better and to come back home and be like, “Excuse me, this is not how we do things. This is not how we say things. I don’t know what it was like in Guyana.”

     Some participants associated this with growing older, and others noted their personal initiative to improve mental health knowledge by following mental health pages on social media, taking a related class, and for some, becoming a part of the mental health field themselves. From this vantage point, many participants were able to equate their previously held notions with beliefs embedded in the culture such as generational rules of respect, gender differences, and the impact of colonialism. Participants, despite their gender differences, noted that within the cultural framework, the rule that mental health should not be discussed is disproportionately applicable to males. Participants shared that this is often due to the perception that it is important for men to be strong, and again, mental illness is a symptom of weakness. This was also linked to the breadwinner role and the pressure to provide for the family. However, this was only noted to have detrimental effects, as anger issues, IPV, and alcoholism were noted to arise out of this rule. Some participants noted that the survival aspect of colonialism may have contributed to the lack of privilege to focus on mental health. In addition, the history of colonialism in Guyana (i.e. slavery, indentured labor) could have informed the lack of trust in professional services.

The change in mental health conceptualization was noted to have benefits beyond the participants themselves. Some participants remarked that the shift in perception was recognized in the wider generation. Ramona reflected:

I will say that a lot of folks from my generation have been a lot more like, “Go to therapy. We should be taking care of our thoughts and our feelings or emotions.” That’s important to you in the same way that if you tore a ligament that you would need to get surgery or do whatever.

     Within the newfound conceptualization of mental wellness emerged a vow of social responsibility. All participants, from both the individual interviews and the focus group, shared their intention to help others, and some even noted it as their duty. Ways to help others included advocating for mental health awareness, access, and education; helping to challenge unhelpful cultural beliefs; breaking generational cycles; and protecting others from experiencing similar struggles (e.g., child, sibling).

Discussion

     The findings from this study are enlightening, and some are the first to be documented through research, even if they were observed in practice. Initial perceptions of all participants, from both the individual interviews and the focus group, were that mental health is a taboo topic and seeking mental health services is bad. These perceptions stemmed from fear, mistrust, and limited awareness of the benefits of mental health services. This is consistent with findings from Arora and Persaud (2020), who surmised that Guyanese individuals hold negative views of mental health that significantly impact their help-seeking. Furthermore, the findings point to strong familial and sociocultural influences, such as beliefs about mental health, that swayed individual perceptions of mental health, which is in keeping with recent literature on affirming cultural strengths and incorporating familial identity in working with clients of Guyanese descent (Groh et al., 2018; Nicolas et al., 2021).

Discussing issues related to mental health was viewed as a sign of weakness, which translated to help-seeking being a taboo. It would appear that the stigma associated with mental health remains a common experience for Guyanese Americans, and when coupled with limited communication, insufficient funding, and lack of providers, we can see how Nicolas et al. (2021) found this to be concerning. Cultural clash, ethnocentric stereotyping, and cultural incompetency may also be responsible for Guyanese Americans being distrustful of the health care system, leading them to engage in maladaptive behaviors (i.e., avoidance, use of substances, IPV) and not receive the mental health attention and care they need (Arvelo, 2018; Cheng & Robinson, 2013; Jackson et al., 2007).

It appears that even in the face of discrimination and experiences of mental health challenges like alcoholism, depression (Hosler & Kammer, 2018), and IPV (Parekh et al., 2012), leaning on the support of the community serves to buffer against mental health challenges for Guyanese Americans. It also seems that changing mental health perceptions from negative to positive was significantly related to mental health literacy and exposure to other systems such as school, work, and community (i.e., cross-cultural exchange).

Findings that were not previously documented in the literature suggest that an integrated view of wellness enabled participants to augment their negative abstractions of mental health care. These findings serve as an indication that among Guyanese Americans, although mental health has been perceived as negative, weak, and a taboo, the narrative is beginning to shift to make space for mental health awareness, education, access, and functioning, thereby creating unique implications for counselors seeking to meet the needs of this immigrant subgroup.

Implications
     In combination with prior literature, the results of this study provide a rationale for mental health counselors, marriage and family counselors, school counselors, and counselor educators to inspire dialogue to foster mental wellness. Based on the findings from this study, when working with Guyanese Americans, counselors should focus on three key strategies to support Guyanese American clients: (a) mental health awareness, (b) mental health education, and (c) mental health experience.

Mental Health Awareness
     Participants in this study initially held limited views and awareness of the signs and symptoms of mental health. When awareness was heightened through various means, they were more open to exploring the benefits of services. Counselors can be instrumental in creating awareness by first raising their own awareness pertaining to cultural stigma and its influence on Guyanese Americans’ mental health. For example, unwillingness to attend counseling sessions may be linked to the culturally held perception that discussing mental health, especially beyond the core family system, is taboo. In acknowledging this, counselors can raise awareness of confidentiality, which can be seen as an alignment with the cultural notion that talking about mental health is taboo when it means talking to anyone, and the role of the counselor can be highlighted as a professional collaboration versus communal gossip. Counselors need to be mindful of the collectivistic nature of Guyanese American culture, which causes personal and familial illnesses alike to be perceived as personal problems. Rather than dismiss a client’s concerns about mental health, a counselor can benefit from exploring how the family members’ symptoms, perceptions about mental health, and willingness to adhere to treatment influence the client’s symptoms, perceptions, and commitment to counseling. Further, collectivism spans beyond the protective family system. On one hand, this community orientation can be used to explore a broad range of support, yet on the other hand, depending on the client’s experience, this may also be a widened range of societal pressure (e.g., judgment, criticism, shame).

Mental Health Education
     Increased understanding of mental health appeared to have led participants to seek services and resources to increase their mental health literacy, with the hope of improving their well-being. Counselors and counselor educators can be instrumental in offering Guyanese Americans mental health education. To begin, all mental health professionals should demonstrate a posture of cultural humility when engaged in psychoeducation on mental health and wellness for this population. In order to raise awareness through education, mental health professionals are encouraged to model trust, respect, sensitivity, compassion, and a nonjudgmental stance. Within session, counselors should be prepared to offer information regarding early signs of mental illness, compounding factors (e.g., alcohol, suicidal ideation, domestic violence), obstacles (e.g., stigma), and resources. Additionally, counselors may need to offer psychoeducation on the family system, roles, dynamics, beliefs, experiences, and generational patterns that can influence individual mental health. In the event that a family member with mental health problems is unwilling to seek assistance, helping the client to better understand the diagnosis and cope personally can be empowering. Finally, to employ the collectivistic nature of Guyanese American culture, stigma can be confronted, and mental health education can be effectively offered by providing group counseling within this population. Group counseling can offer a variety of therapeutic factors that can benefit Guyanese Americans such as universality, hope, and corrective recapitulation of the primary family group (Yalom & Leszcz, 2005).

Beyond the counseling office, counselors and counselor educators should consider collaborating with culturally supportive organizations. Workshops and information sessions can be tailored to explore and address cultural, religious, ethnic, and generational differences in addition to offering mental health resources (e.g., signs, symptoms, treatment). Several of the participants in our study shared that access to psychology courses in school helped to improve their knowledge about mental health. In addition to these classes continuing to be offered, accessibility to such courses should be expanded. Schools and universities may benefit from offering workshops and other informational sessions to support mental health. Beyond information being offered, a follow-up may be beneficial by linking school or campus counselors in order to connect an improvement in awareness and education to action, change, and health.

Several participants shared that because of a lack of access to mental health education, their knowledge was attained through social media platforms such as Instagram and TikTok. Although the quality of mental health education was not assessed in the present study, the lack of regulation on social platforms could perpetuate misleading, confusing, and stigmatizing misinformation surrounding mental health. Counselor educators should consider their roles beyond the classroom. In addition to empowering counselor trainees to utilize the suggestions above to foster awareness and education, counselor educators can offer responsive and succinct information via social media. Whereas social media is not an appropriate platform for tailored education or services, brief information can be offered to bridge the gap between awareness, education, and access.

Mental Health Experience
     Growth in awareness and knowledge around mental health resulted in participants intentionally engaging in positive experiences as a way of resisting past harmful and hurtful practices and generational patterns, reauthoring a new narrative of hope and healing. Being wellness-focused, counselors are uniquely positioned to support this community by facilitating positive experiences impacting overall mental health and well-being.

Counselors can honor clients from this community by creating safe spaces for them to share their narratives without judgment. Counselors can foster healing communities through group counseling, where clients collaboratively share each other’s mental burdens and celebrate successes (Yalom & Leszcz, 2005). Counselors can honor collectivism by encouraging clients to participate in support groups in addition to personal counseling. Counselors and counselor educators can enhance the approachability of counselors by improving their visibility in the community. Examples include a community counselor being involved in outreach with a local cultural center, a school counselor offering mentorship with student clubs, a college counselor guest-speaking at a Guyanese American student organization meeting, or a counselor educator offering tailored workshops for the community.

In addition to the aforementioned implications, we believe that in order for counselors to bridge generational gaps in counselor distrust, counselors must acknowledge the lack of representation of diversity within the profession of counseling, the predominance of Western and European cultural and psychologist-centered curriculum, and lapses in poor bioethics and power dynamics among counselors and marginalized communities (Singh et al., 2020). Next, the specific intersectional impacts suggest counselors must adapt a multicultural orientation and illuminate cultural sensitivity. When a clinician enacts cultural sensitivity in session, clients can examine their perceptions of illness and center their multiple identities (Davis et al., 2018).

Limitations and Future Research
     Several limitations that arose from the research process are important to mention. All interviews were conducted virtually. Although secured virtual platforms such as Zoom are considered acceptable for research, lack of face-to-face interviewing may have excluded subtle visual cues and induced video-conferencing fatigue (Spataro, 2020). Though researchers made great attempts to increase participant comfort and review the informed consent before the interview process, it is also plausible that respondents may have censored their responses out of concern for potential breach in confidentiality. A majority of respondents are college-educated, female, first generation, and of Indo-Guyanese descent; hence, the results may not be representative of all Guyanese Americans. Additionally, aligned with phenomenological methods of exploring lived experiences, research prompts were general. Recognizing the concerning statistics surrounding suicide (WHO, 2014), a future study exploring suicidality could be beneficial. Future research might seek to explore a more diverse pool of participants, including diversity in gender, age, ethnicity, and number of years in the United States. To build on the findings from the present study, future studies should explore what factors contribute to Guyanese American mental health as well as what variables may hinder mental wellness. It may also be beneficial to include research from the perspective of children and parents to further understand the influence of family systems and cross-generational norms.

Conclusion

This study highlighted the crucial need to address the mental health literacy of Guyanese Americans. The findings illuminate Guyanese Americans’ perceptions of mental health, including the transition from negative to positive perceptions and its potential influences. Efforts should be made to promote awareness, education, and experience related to mental health awareness for Guyanese Americans. Supporting mental health may help to reduce alarming rates of mental illness in Guyanese Americans and may also have the potential to influence related groups such as Guyanese, American, and Caribbean individuals. Counselors and counselor educators have the potential to play a significant role in supporting these clients by being cognizant and informed about cultural considerations.

 

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

References

American Counseling Association. (2014). ACA code of ethics. https://www.counseling.org/resources/aca-code-of-ethics.pdf

Arora, P. G., & Persaud, S. (2020). Suicide among Guyanese youth: Barriers to mental health help-seeking and recommendations for suicide prevention. International Journal of School & Educational Psychology, 8(1), 133–145. https://doi.org/10.1080/21683603.2019.1578313

Arvelo, S. D. (2018). Biculturalism: The lived experience of first- and second-generation Guyanese immigrants in the United States (Order No. 10749930) [Doctoral dissertation, Chicago School of Professional Psychology]. ProQuest One Academic. (2027471070).

Baboolal, A. A. (2016). Indo-Caribbean immigrant perspectives on intimate partner violence. International Journal of Criminal Justice Sciences, 11(2), 159–176. https://www.researchgate.net/publication/336926774_Indo-Caribbean_Immigrant_Perspectives_on_Intimate_Partner_Violence

Buchholz, K. (2022, November 11). The world’s biggest diasporas [Infographic]. Forbes. https://www.forbes.com/sites/katharinabuchholz/2022/11/11/the-worlds-biggest-diasporas-infographic/?sh=4185fd634bde

Cavalcanti, H. B., & Schleef, D. (2001). Cultural loss and the American dream: The immigrant experience in Barry Levinson’s Avalon. Journal of American and Comparative Cultures, 24(3–4), 11–22.
https://doi.org/10.1111/j.1537-4726.2001.2403_11.x

Cheng, T. C., & Robinson, M. A. (2013). Factors leading African Americans and Black Caribbeans to use social work services for treating mental and substance use disorders. Health & Social Work, 38(2), 99–109. https://doi.org/10.1093/hsw/hlt005

Creswell, J. W. (2013). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). SAGE.

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., Van Tongeren, D. R., Worthington, E. L., Jr., & Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89–100. https://doi.org/10.1037/pst0000160

Forte, A., Trobia, F., Gualtieri, F., Lamis, D. A., Cardamone, G., Giallonardo, V., Fiorillo, A., Girardi, P., & Pompili, M. (2018). Suicide risk among immigrants and ethnic minorities: A literature overview. International Journal of Environmental Research and Public Health, 15(7), 1–21. https://doi.org/10.3390/ijerph15071438

Groh, C. J., Anthony, M., & Gash, J. (2018). The aftermath of suicide: A qualitative study with Guyanese families. Archives of Psychiatric Nursing, 32(3), 469–474. https://doi.org/10.1016/j.apnu.2018.01.007

Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18(1), 59–82. https://doi.org/10.1177/1525822X05279903

Haskins, N. H., Parker, J., Hughes, K. L., & Walker, U. (2022). Phenomenological research. In S. V. Flynn (Ed.), Research design for the behavioral sciences: An applied approach (pp. 299–325). Springer.

Hays, D. G., & Singh, A. A. (2012). Qualitative inquiry in clinical and educational settings. Guilford.

Hays, D. G., & Wood, C. (2011). Infusing qualitative traditions in counseling research designs. Journal of Counseling & Development, 89(3), 288–295. https://doi.org/10.1002/j.1556-6678.2011.tb00091.x

Heron, M. (2021). Deaths: Leading causes for 2019. National Vital Statistics Reports, 70(9), 1–113. https://doi.org/10.15620/cdc:107021

Hosler, A. S., & Kammer, J. R. (2018). A comprehensive health profile of Guyanese immigrants aged 18–64 in Schenectady, New York. Journal of Immigrant and Minority Health, 20(4), 972–980.
https://doi.org/10.1007/s10903-017-0613-5

Hosler, A. S., Kammer, J. R., & Cong, X. (2019). Everyday discrimination experience and depressive symptoms in urban Black, Guyanese, Hispanic, and White adults. Journal of the American Psychiatric Nurses Association, 25(6), 445–452. https://doi.org/10.1177/1078390318814620

Hunting, G. (2014). Intersectionality-informed qualitative research: A primer. The Institute for Intersectionality Research and Policy. https://nanopdf.com/download/intersectionality-informed-qualitative-research-a-primer-gemma-hunting_pdf

Indo-Caribbean Alliance, Inc. (2014, February 3). Population analysis of Guyanese and Trinidadians in NYC.
https://www.indocaribbean.org/blog/population-analysis-of-guyanese-and-trinidadians-in-nyc

Jackson, J. S., Neighbors, H. W., Torres, M., Martin, L. A., Williams, D., & Baser, R. (2007). Use of mental health services and subjective satisfaction with treatment among Black Caribbean immigrants: Results from the National Survey of American Life. American Journal of Public Health, 97(1), 60–67. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1716231/

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. SAGE.

Marshall, C., & Rossman, G. B. (2006). Designing qualitative research (4th ed.). SAGE.

Moustakas, C. (1994). Phenomenological research methods. SAGE.

Nicolas, G., Dudley-Grant, G. R., Maxie-Moreman, A., Liddell-Quintyn, E., Baussan, J., Janac, N., & McKenny, M. (2021). Psychotherapy with Caribbean women: Examples from USVI, Haiti, and Guyana. Women & Therapy, 44(1–2), 136–155. https://doi.org/10.1080/02703149.2020.1775993

One World Nations Online. (n.d.). Guyana. https://www.nationsonline.org/oneworld/guyana.htm

Onwuegbuzie, A. J., & Leech, N. L. (2007). A call for qualitative power analyses. Quality & Quantity, 41, 105–121. https://doi.org/10.1007/s11135-005-1098-1

Parekh, K. P., Russ, S., Amsalem, D. A., Rambaran, N., Langston, S., & Wright, S. W. (2012). Prevalence of intimate partner violence in patients presenting with traumatic injuries to a Guyanese emergency department. International Journal of Emergency Medicine, 5(1), 1–5. https://doi.org/10.1186/1865-1380-5-23

Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2015). Multicultural and social justice counseling competencies. American Counseling Association. https://www.counseling.org/docs/default-source/competencies/multicultural-and-social-justice-counseling-competencies.pdf

Singh, A. A., Appling, B., & Trepal, H. (2020). Using the Multicultural and Social Justice Counseling Competencies to decolonize counseling practice: The important roles of theory, power, and action. Journal of Counseling & Development, 98(3), 261–271. https://doi.org/10.1002/jcad.12321

Spataro, J. (2020). The future of work—the good, the challenging & the unknown. https://www.microsoft.com/en-us/microsoft-365/blog/2020/07/08/future-work-good-challenging-unknown/

Statimetric. (2022). Distribution of Guyanese people in the US. https://www.statimetric.com/us-ethnicity/Guyanese

United States Census Bureau. (2019). People reporting ancestry: American community survey. http://bit.ly/42RazKC

Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial differences in physical and mental health: Socio-economic status, stress and discrimination. Journal of Health Psychology, 2(3), 335–351.
https://doi.org/10.1177/135910539700200305

World Health Organization. (2014). First WHO report on suicide prevention. https://www.who.int/news/item/04-09-2014-first-who-report-on-suicide-prevention

World Population Review. (2023). Suicide rate by country 2023. https://worldpopulationreview.com/country-rankings/suicide-rate-by-country

Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). Basic Books.

 

Shainna Ali, PhD, NCC, ACS, LMHC, is the owner of Integrated Counseling Solutions. John J. S. Harrichand, PhD, NCC, ACS, CCMHC, CCTP, LMHC, LPC-S, is an assistant professor at The University of Texas at San Antonio. M. Ann Shillingford, PhD, is an associate professor at the University of Central Florida. Lea Herbert is a doctoral student at the University of Central Florida. Correspondence may be addressed to Shainna Ali, 3222 Corrine Drive, Orlando, FL 32803, hello@drshainna.com.