Rebekah F. Cole, Rebecca G. Cowan, Hayley Dunn, Taryn Lincoln
Newly released data from the U.S. Department of Defense shows military spouse suicide to be an imminent concern for the U.S. military. Currently, there is an absence of research in the counseling profession related to suicide prevention and intervention for this population. Therefore, this qualitative phenomenological study explored the perceptions of military spouses regarding suicide within their community. Ten military spouses were interviewed twice and were asked to provide written responses to follow-up questions. Six main themes emerged: (a) loss of control, (b) loss of identity, (c) fear of seeking mental health services, (d) difficulty accessing mental health services, (e) the military spouse community as a protective factor, and (f) desire for better communication about available mental health resources. Implications for practicing counselors and military leadership in helping to prevent military spouse suicide as well as recommendations for future research regarding ways to support military spouse mental health and prevent suicide in this community are included.
Keywords: military spouse, suicide, prevention, intervention, phenomenological
In 2018, there were 624,000 active-duty military spouses in the United States, 92% of whom were female (U.S. Department of Defense [DOD], 2018). Recent data also noted that the average age of a military spouse was 31.5 years and 88% of spouses had postsecondary education (U.S. Chamber of Commerce, 2017). Twenty-four percent of spouses were unemployed (DOD, 2018) and 35%–40% were underemployed (U.S. Chamber of Commerce, 2017). Further, 74% of military spouses had children under the age of 18 and often acted as single parents because of the responsibilities of the service member (Institute for Veterans and Military Families, 2016). And of particular note, the Substance Abuse and Mental Health Services Administration (SAMHSA; 2015) reported that 29.1% of military spouses have had a mental illness, with 11.8% having had at least one major depressive episode, and 6.5% having had a major depressive episode with severe impairment.
Military Lifestyle and Spousal Mental Health
Military spouses do not serve in combat as service members do, but they are subject to many stressors brought on by the military lifestyle that may affect their mental health (Cole, 2014). One of the primary stressors of the military lifestyle is frequent moving (Tong et al., 2018). Military families move every 2–3 years to a new location (Burke & Miller, 2016), which they may not have adequate time to prepare for, adding to the stress of the relocation process (Tong et al., 2018). Military spouses may feel isolated after moving, as 70% of military families live in civilian communities rather than in military housing (Blue Star Families, 2019). Although social support has been found to be key in ameliorating mental health issues in military spouses (Ross et al., 2020), this support is lost and must be rebuilt when the family moves to a new duty station.
Because of these frequent moves, military spouses are often unable to build consistent careers or finish their education (Institute for Veterans and Military Families, 2016). Relocating spouses may experience difficulty finding a new job or utilizing their professional license or certification in their new home state or country (DOD, 2020b). As a result of these lifestyle challenges, 24% of military spouses are unemployed (DOD, 2018) and 77% of employed spouses have been underemployed at least once (Blue Star Families, 2019). These employment challenges often result in anxiety and depression among military spouses (Linn et al., 1985). In addition, the inability to find work may result in financial stress for the family and often affects spousal mental and behavioral health (Blue Star Families, 2019; Center for the Study of Traumatic Stress, 2020).
In addition to stressful relocations and career disruption, spouses also face frequent deployments of their partners (Allen et al., 2011). These deployments result in increased depression and anxiety in spouses (Baer, 2019; Eaton et al., 2008; O’Keefe, 2016), with 92% of spouses reporting increased stress during a deployment, and 85% reporting that they feel anxious or depressed during a deployment (Romo, 2019). This deployment stress may be amplified when the spouse lives overseas and is away from their friends and family in an unfamiliar culture (McNulty, 2003). When their service member is deployed, military spouses have to take on new roles and responsibilities in the home, which may contribute to these high stress levels (Eaton et al., 2008). In addition, they may live in constant fear for their service member’s physical safety, as they are unable to contact their spouse regularly, or communication may be limited to social media with inherent limits to tone or context that prove to be anxiety-inducing (Allen et al., 2011; O’Keefe, 2016).
Military Spouses and Mental Health Treatment
Although military spouses are under constant stress in their everyday lives (Cole, 2012; Eaton et al., 2008; Mailey et al., 2018), they often resist seeking mental health treatment (Lewy et al., 2014). Past studies have revealed that spouses often do not seek therapy because they cannot locate a counselor they trust or who understands their culture, they are concerned that someone will find out they are seeking counseling, or they do not know where to find counseling services (Lewy et al., 2014). The stigma that military spouses fear regarding mental health treatment affecting their service member’s career progression mirrors that of the active-duty service member population (Britt et al., 2015). In addition, the pressure that spouses feel to take care of their families without their service member’s support and the sense that they must prioritize their families before themselves has led them to resist receiving mental health help for themselves (Mailey et al., 2018). When they do seek mental health services, spouses are likely to visit their primary care doctor at a military care facility; however, these facilities are not equipped to meet spouses’ mental health needs because of lack of personnel and resources for specialized mental health services (Eaton et al., 2008; Lewy et al., 2014).
Military Spouses and Suicide
Although many of these studies have focused on risk factors and barriers for military spouse mental health treatment, no research has focused on the consequences of these barriers, including suicide in this population. Although much focus has been placed on researching service member and veteran suicide (Blosnich et al., 2010), statistics regarding military spouse suicide were recently tracked for the first time and released to the public in September 2019 (DOD, 2019). In 2018, 128 military spouses died by suicide, with a suicide rate of 12.1 deaths per 100,000 individuals (DOD, 2020a). Of those who committed suicide, 57.8% were female and 85.1% were under the age of 40. Given the alarming numbers of spousal suicide outlined in the DOD report, it is essential that pioneering research be done to investigate suicidality in the military spouse population. This study, therefore, explored the perceptions of military spouses related to suicide in this population by interviewing military spouses themselves, who are the experts on the military spouse lifestyle and experience (Sargeant, 2012). The purpose of this study was not to focus on the experiences of spouses who have themselves attempted suicide, but rather how members of the military spouse population made meaning of suicide within their community. Thus, a qualitative phenomenological design was appropriate for exploring this meaning making (Christensen et al., 2017; Creswell & Poth, 2017). As experts on their own community and experiences, the participants provided perceptions that proved valuable in understanding the causes and risk factors associated with suicide in this population.
Purpose Statement and Research Questions
The purpose of this qualitative phenomenological study was to explore the perceptions of military spouses related to military spouse suicide and how these spouses made meaning of suicide within the military spouse community. Based on the perceptions and recommendations of the participants, this study makes suggestions to the civilian and military communities regarding best practices for preventing suicide in and providing mental health services for this population. This study was guided by the following research questions:
- What are the perceptions of military spouses of suicide in the military spouse community?
- What are the perceptions of military spouses regarding resources to prevent military spouse suicide?
Our research team utilized the descriptive phenomenological tradition in qualitative inquiry, in which the researcher explores the participants’ meaning-making experience and how they translate this experience into their consciousness (Christensen et al., 2017; Creswell & Poth, 2017). In order to gather information and perspective regarding suicide within the military spouse community, Rebekah F. Cole, our team’s principal investigator, interviewed 10 spouses of active-duty service members, using a semi-structured interview, to explore their experiences in-depth and to understand how they make meaning of suicide within the military spouse community. A qualitative researcher does not aim to generalize but to draw out depth of insight from participants; hence, a small sample size was appropriate and justified with the aim of collecting a wealth of information from each participant (Creswell & Poth, 2017). Cole interviewed each spouse two times for approximately 30 minutes over the course of 4 weeks and then sent each participant an email with follow-up reflection questions (e.g., “What was it like for you to participate in this study?”) and demographic questions regarding the participants’ age group, gender, race/ethnicity, military branch, years as a spouse, and spouse’s rank.
We selected the participants based on their status as active-duty spouses as well as their willingness and availability to participate in two interviews and complete the follow-up questions. We identified and recruited participants via purposeful sampling following approval by the IRB at our university (Creswell & Poth, 2017). Cole made a posting on a military spouse Facebook page explaining the nature and purpose of the study and asking for volunteers who were married to an active-duty service member. We offered each participant a $250 Target gift card to participate in the study, given to them upon completion of the two interviews and return of the emailed follow-up questions. We selected the first 10 volunteers who responded to the Facebook post as the 10 participants in this study. Once they showed interest in participating in the study, Cole contacted each participant via email to explain the nature and goals of the study and provide the participants with the informed consent document to sign and return.
The participants in this study were all spouses of active-duty service members (see Appendix A for a demographic chart). Three of the participants were Army spouses, three were Air Force spouses, three were Navy spouses, and one was a Coast Guard spouse. Two of the spouses were in the 18–29 age range, five were in the 30–39 age range, and three were in the 40–49 age range. The time spent as a spouse ranged from 1–20 years with a mean of 9.5 years. Eight of the spouses identified as White or having a European heritage and two of the spouses identified as having Asian or Pacific Islander heritage. All of the spouses identified as female. The participants were assigned numbers (Participant 1, Participant 2, etc.) to protect their confidentiality throughout the study.
The research team in this study consisted of Cole and two school counseling graduate students, Hayley Dunn and Taryn Lincoln. These students had been trained in research methodology and were familiar with the qualitative data analysis process. Lincoln is a 35-year-old White female whose husband is a retired service member. Dunn is a 33-year-old White female with no military connections. Cole worked closely with Dunn and Lincoln to review the transcriptions of the interviews, develop a comprehensive codebook, and discuss the themes and patterns that emerged from the data.
Cole conducted and recorded the interviews via phone. She transcribed the interviews using an automated transcription service and reviewed each transcription word-by-word to verify the accuracy and reliability of the transcription (Creswell & Creswell, 2018; Creswell & Poth, 2017). In each interview, Cole asked questions related to suicide in the spouse population (see Appendix B). She also utilized probing follow-up questions (e.g., “Can you tell me more about that?” or “Why do you think that is?”) to gather additional information throughout the interviews (Creswell & Creswell, 2018). Finally, Cole sent a follow-up email consisting of process questions related to the interview experience (see Appendix B) as well as demographic questions.
We analyzed the data in a step-by-step process: 1) organizing the data, 2) looking over all of the data, 3) coding the data, 4) generating a description of themes, and 5) presenting the description of themes (Creswell & Creswell, 2018). Cole first organized the data, sorting each participant’s file and memoing ideas that began to emerge from the data (Creswell & Creswell, 2018; Creswell & Poth, 2017). We then each reviewed the transcripts and email responses in detail. After reviewing the data, we coded the interviews and follow-up questions. Cole compiled the codes that we generated into a codebook. We then identified and defined themes and patterns that emerged from the study. This collaboration continued until we decided that no additional themes and patterns were emerging from the data. Cole then sent the codebook, as well as the themes and patterns, to the external auditor of the study, Rebecca G. Cowan, who confirmed the findings of the research team. Cole then wrote a detailed narrative of the themes, which are presented in the Findings section of this article.
Strategies to Increase Trustworthiness
In order to increase trustworthiness of the study, Cole, the key data collector in this study, engaged in reflexivity and self-analysis throughout the study (Creswell & Creswell, 2018; Darawsheh, 2014; Meyer & Willis, 2019). As a military spouse and professional counselor, Cole inherently has her own thoughts and feelings related to spousal mental health. Thus, it was important to bracket these thoughts and feelings to prevent them from interfering with the data collection and analysis process. Cole used reflective journaling throughout the study to engage in self-reflection and to increase her self-awareness of her reactions to the participants’ perspectives (Malacrida, 2007; Meyer & Willis, 2019). She also discussed these thoughts and feelings with the research team to explore her position as the researcher in the context of this study (Barrett et al., 2020).
In addition to this reflexivity, Cole kept an audit trail throughout the study, which included the transcriptions of the interviews, the participants’ emailed responses, the codebook, reflexive journal entries, and the notes from the research team (Creswell & Creswell, 2018; Creswell & Poth, 2017). Cowan, an auditor with a PhD in counselor education who has been a counselor and counselor educator for the past 10 years, reviewed the study in full to verify the data collection and analysis process (Creswell & Creswell, 2018) as well as the rigor of the study (Patton, 2002).
To triangulate the study’s data and increase the validity of the study’s results, data were collected through two individual interviews as well as through an email questionnaire, both open-ended forms of data collection (Creswell & Creswell, 2018). Prolonged engagement assisted with the development of trust and rapport (Korstjens & Moser, 2018). Additionally, through the collection of both verbal and written data, the study’s themes gained more credibility, as they emerged from both data sources (Creswell & Creswell, 2018).
Finally, we used member checking (Creswell & Creswell, 2018) to request the participants’ feedback on the credibility of the data (Creswell & Poth, 2017). Member checking allows the study’s participants to become actively involved in and make additions to the data review process (Birt et al., 2016). Cole emailed the participants transcriptions of their interviews and asked them to review and make any additions or changes they would like to the transcriptions, allowing them ownership of their thoughts and words and increasing the trustworthiness of the data (Birt et al., 2016). In addition, Cole discussed the findings of the study with the participants as the themes and patterns emerged (Shenton, 2004).
The study’s data yielded six main themes: (a) loss of control, (b) loss of identity, (c) fear of seeking mental health services, (d) difficulty accessing mental health services, (e) the military spouse community as a protective factor, and (f) desire for better communication about available mental health resources.
Theme 1: Loss of Control
Each of the 10 participants perceived their circumstances as a military spouse to be out of their control. For example, all of the participants mentioned deployments, especially those on short notice, to be a risk factor for suicide. One spouse described how her active-duty husband “might be home on Thursday and then he’s gone the next day. He finds out on such short notice, that’s really tricky, and a lot of my friends are constantly, you’re just so constantly anxious all the time.”
Four of the participants described how they fear for their spouse’s safety during these deployments, which impacts their mental health. One spouse, for example, described how she lives “just constantly not knowing what’s happening, but then being fearful for the significant other as well.” Another spouse explained how spouses live with a “constant fear of whether or not your spouse will return.” One participant discussed how military spouses are thus more prone to mental health issues:
[T]he stress of your life and the stress you have over your spouse’s military career, whether they’re in danger or not, worrying about their mental health . . . probably aggravates all of the mental disorders that anyone could experience, but just magnifies them if you’re a military spouse.
Participants also felt like they lacked control because of frequently relocating. All 10 participants described the stress involved with moving unpredictably. One spouse described how “you’re always worried about what’s coming next and what you can plan for and what you can’t plan for.” Another participant mirrored this same sentiment: “It’s that ‘Where are we going to be next? We just moved here, but I know in two years we’re going to move again’ type deal . . . always just kind of being on your toes and not knowing what to expect.” Another spouse expressed similar thoughts: “I hope for the best but expect the worst, which is kind of sad, but that is the kind of mentality I’ve had to live by because of how unpredictable this lifestyle is.”
As a result of these constant relocations, spouses are separated and isolated from family and friends, or their “network of support” in the words of one participant. All of the participants recognized the risk of losing this support with regard to their mental health. One spouse, for example, explained the danger of not having “long-standing relationships where you could say like, ‘Wow that person really seems like they’re going through something.’”
Theme 2: Loss of Identity
All 10 participants struggled with a loss of their identity, especially regarding their careers. Many participants described how career struggles and finding purpose are related to spousal mental health. One spouse explained how “not having that career is part of the anxiety and depression. And not having a purpose in life.” Another spouse described the struggle to maintain a career: “Eventually, it kind of weighs on you and eventually your mind can play tricks on you and you feel like you’re not worthy.” One participant summed up these career struggles in these words: “Part of being a military spouse is sacrificing your own life . . . there’s a lot of hurt and loneliness and sacrifice.”
In addition to this struggle for career identity and purpose, five of the participants described how the military fails to recognize their value. One spouse described how spousal suicide “is definitely brushed under the rug because people are kind of like, ‘You’re not going to war, you’re not doing any of these things.’” Another participant described her own experiences: “We’ve had situations where wives were struggling, but . . . he couldn’t get off that day, he had to report in because she’s not at the hospital . . .it’s not serious.” Another explained how “the military in general, they’re so focused on their job that they kind of forget that we’re all humans and that we are people.” One participant said that “spouses get beat down and they just kind of feel like there’s the whole ‘If the military wanted you to have a family, they would have issued you one.’”
The participants also described the military spouse’s tendency to prioritize family and the military over oneself and the impact of this inclination on spouses’ mental health. “So much of the burden of the family falls onto the military spouse, I think it’s easy for the spouse to not consider their own mental health a priority, and therefore the risk factors may go undetected or untreated.” Another described how spouses “go through this constant cycle that’s always churning. You move to a new place, you try to get settled . . . then we hit the point of going, ‘Ok, now what about me?’ If we ever get to that point.” One spouse described that after each of the moves and deployments, “I feel like we lose a sense of ourselves too . . . it’s like having a new baby all of the time. . . . You kind of reach a point where you’re like, ‘Where am I? What the heck am I doing?’”
As a result of prioritizing family and the military over themselves, spouses feel unworthy of receiving mental health services and feel guilty for suffering, as described by eight of the participants. One spouse explained that “spouses can feel weak or feel like they’re not holding up their end of the bargain if they get help.” Another participant noted that spouses “consider themselves less worthy of getting treatment or that their problems [are] not as important.” Finally, a spouse explained that there is a “weird mentality, I think, in the military spouse community, where you don’t complain because someone else has it worse. . . . If you’re an Air Force spouse, maybe the Army deployments are longer, so you just don’t want to complain.”
Theme 3: Fear of Seeking Mental Health Services
Despite these challenges that military spouses face, eight of the participants described a fear of seeking out mental health services. Five of the participants, for example, said that spouses fear appearing to be unstable or, as one spouse described, a “fear of being ostracized, or the fear of having people talk behind your back, or embarrassment.” One spouse explained how mental health issues are viewed as, “Oh, she was a crazy spouse. Oh, she got everything that she needed . . . so she was just kind of crazy.” Another participant described how a spouse was viewed after verbalizing her mental health struggles: “I’ve been told by other spouses not to go hang out with her in group settings because she’s batshit crazy.” One spouse noted that “there’s still that stigma of reaching out and being known to have the mental health issue.” Finally, spouses may fear being honest with their medical providers for this same reason. One participant described her own perception of this fear of being transparent with the doctor regarding a suicidal assessment: “If you answer it honestly, sometimes you’re like ‘They’re going to put me in a padded room if I really tell you what my last 2 weeks has been like.’”
In addition to appearing unstable, seven of the participants described how military spouses fear that seeking mental health services would negatively impact or bring “backlash” on their service member’s career. One participant noted: “People keep it quiet because they don’t want their spouse, their military member, to not get promoted or not get more responsibility and stuff like that because they’re not keeping it together.” Another participant stated that often “you run into people who are kind of skittish about going just because of the stigma.” She further explained that “you don’t want to hurt your husband’s career, and that’s what you’ve heard for a long time. He looks like he can’t handle the situations at home.’”
Theme 4: Difficulty Accessing Mental Health Services
Spouses who do decide to seek help for their mental health may experience difficulties in securing an appointment, as described by six of the participants in this study. Each of these spouses expressed difficulties with finding a mental health provider in the community or accessing mental health treatment at a military facility. One participant explained that “the reality is they can’t guarantee that the local community and local providers will be able to provide everything we need when we need it.” Another spouse expressed frustration that “TRICARE can sometimes be a pain when you’re trying to schedule something, and it will make you schedule at 6 weeks out because that’s the first available.” One participant described her experience with trying to find a counselor covered by TRICARE. She stated, “You hope that you get an appointment and hope you can jive with whoever you called because you may have to wait another month or two to try to find someone else.” Three spouses in the study also expressed concern about the consistency of care due to frequent relocations. One participant explained the need to streamline mental health services at each duty station “so that if [spouses] are seeing a psychiatrist in one place and they go to the next place, they’re not waiting for 2 or 3 months before they can get in to see a new psychiatrist.”
Five of the study’s participants also expressed concern over not having access to a mental health specialist. For example, one spouse shared that “the person I did see, who was a social worker, I just don’t feel was very equipped to talk to me about the things I wanted to talk about.” Another spouse described her perception of military family life consultants’ work with spouses on military bases:
They just kind of give them the same spiel, like you should exercise, make sure you’re eating well, getting enough sleep, instead of saying, “You know what? This is outside of the realm of what I can handle, let’s get you in to the type of professional that you need.”
Theme 5: The Military Spouse Community as a Protective Factor
In the midst of these mental health challenges and difficulty seeking and accessing mental health services, seven of the participants described the military spouse community as a protective factor against suicidal ideation. As one participant explained, “Anyone can try to take their own life, but if they have people around them who are looking out for them, who are with them physically and emotionally, it’s harder to do.” In addition, one participant pointed out that the spouse community can offer a sense of shared understanding: “Someone else probably very close by has gone through the same thing that you have . . . and you’re not the first person to go through this and someone might be able to help lighten your load.” The participants emphasized the need to create “a friendly, inclusive environment where spouses can network and establish relationships” as well as establish a “connection and feeling of belonging.” One participant noted that within this environment and community, it is important to normalize conversations about mental health in order to decrease the stigma attached to it. “Letting people see that while we might post pretty pictures on Facebook and someone looks all together when they’re at that unit function, we’ve all had to reach out for help, and looking at that as being strong.”
To increase this protective factor as a community, six spouses described the importance of training for spouses geared toward suicide prevention so they could recognize the signs of suicide in others. One spouse said that training in “prevention measures of how to spot suicide, signs of suicide, or who to talk to, where to go, what to say” would be helpful “because spouses are probably already witnessing all of these signs in their homes or in their neighbors or in their friend groups of depression and suicidality.” Another participant described how “spouses could be looking out for friends, if they know some warning signs or give friends resources to go to so their friend could find it if they need help.”
Theme 6: Desire for Better Communication About Available Mental Health Resources
Each of the 10 participants expressed the need for the military to communicate more with them about mental health resources. One spouse, for example, pointed out that such “information needs to be put out there clearly at military hospitals, on military bases. . . . So I think the military could make it more clear, destigmatize it, and just make the programs more widely available and advertised.” In this proposed advertisement, the spouses would want to know “what kind of help we can get, what it costs, where we can get help, and will it matter to our spouse’s career?”
In addition to this suggested advertising, six of the participants said they would like the military leadership to communicate with them directly regarding available mental health resources specifically designed for spouses. One participant described how “it’s harder for the spouse to get that information . . . if they had information sent directly to them, I think they would be more willing to seek it out and use those resources.” Another spouse noted that “military spouses need to be presented with the resources available for their mental health directly instead of solely relying on the service member to relay the information.” As a result of receiving this information on resources available specifically for them, one participant explained that “the military spouse wouldn’t have to consider themselves less worthy of getting treatment or that their problems [were] not as important.”
Finally, six of the spouses suggested that the check-in process for each duty station could be a key opportunity to provide spouses with resources and preventative services. One spouse noted: “I think that when you move somewhere new there should be someone checking to make sure you’re okay and you’re not alone all the time. I think it’s the military’s responsibility to make sure there’s a process in place.” Another spouse proposed this check-in process as being “part of the standard procedure to make sure the spouse maybe is brought in and made aware of all of the programs that are available to them.”
In this study, all of the military spouse participants described how spouses’ loss of control and loss of identity may contribute to their increased risk for suicide. These feelings resulted from continually moving to new duty stations (often unexpectedly), being isolated and separated from their support systems, fearing for their spouse’s safety during deployments, and struggling to maintain a sense of self and a career while making their families and the military their priority. Although they were committed to prioritizing the military lifestyle and their spouses’ career, these spouses did not feel that their needs were prioritized by the military in turn.
Each of these challenges for military spouses has been previously addressed in the professional literature (Eaton et al., 2008; Lewy et al., 2014; Mailey et al., 2018), although their direct correlation to suicidality has not yet been explored. Because increased levels of suicidality have been found in other populations when social isolation increases (Calati et al., 2019; Heuser & Howe, 2019; Pompili et al., 2007) or stressful life transitions or events occur (Oquendo et al., 2014; Paul, 2018), it is important to continue to consider how these risk factors impact military spouses’ suicidality.
Most of the participants likewise described the tendency of spouses to feel guilty for suffering, as they are not the ones on the battlefield, a new phenomenon not yet explored in the professional literature. One participant concluded that these feelings of guilt may lead to spouses feeling they are unworthy of using mental health resources intended for active-duty service members. To address these feelings of guilt, one spouse described the need to normalize the conversation about mental health among spouses, which would ameliorate these feelings of unworthiness and increase spouses’ use of resources. Finally, all of the participants felt that provision and advertisement of mental health and suicide prevention programs and services specifically for spouses would help them feel more confident in utilizing these services.
When speaking about risk factors associated with suicide, most spouses described their fears of the stigma associated with accessing mental health services and the struggles associated with finding mental health providers qualified to help them when they did decide to seek help. These fears and struggles directly correspond to results in past quantitative and mixed-methods research regarding barriers to treating military spouse mental health (Eaton et al., 2008; Lewy et al., 2014). The participants in this study likewise described their frustration with not being able to get an appointment with military or community providers. These struggles echo the results of previous research describing the challenges of spouses to access mental health services (Lewy et al., 2014), highlighting the consistency of this issue.
Although the participants’ struggles with mental health and mental health providers confirm the findings of existing studies, their suggestions for preventing suicide within the military spouse community are new ideas generated from this study. Primarily, the participants focused on the community itself as a protective factor against suicide. They described how building a strong spousal community prevents feelings of isolation, as spouses can care for each other because they share common experiences of the military lifestyle. This sense of connection is especially important, as spouses are separated from their support systems when relocating from one duty station to the next (Ross et al., 2020). In order to strengthen the protective factor of their community, the spouses discussed how they wanted more training from military leadership in the areas of suicide prevention and intervention so that they can help others around them. Interestingly, contradictory themes arose in this study’s findings regarding the spouse community shunning those who were struggling with mental health issues and the spouse community serving as a much-needed protective factor. Perhaps the participants’ suggestions of focusing on normalizing mental health support within their community would help to reduce the current tendency to shun and would increase the tendency to support.
In addition to focusing on increasing the protective factor of the spouse community itself, all of the participants stated that they desired increased communication from the military regarding mental health services and programs available specifically to them. Some of the spouses suggested that a direct line of communication from military leadership to spouses would be helpful for finding out about mental health resources available to them, as well as to their spouses. This communication would involve more strategic and widely spread advertising about suicide prevention resources and mental health services in places that spouses often frequent, such as military hospitals or on-base/on-post facilities.
Finally, several spouses suggested an innovative, structured check-in process at each duty station that would promote spousal awareness and understanding of the resources available to them. They explained that this check-in would provide an immediate sense of connection and community for the spouse and a way to formally network with other spouses in the area. This formalized check-in process carried out by the administration at the new duty station may be especially helpful for newer spouses who may not be familiar with the military’s mental health resources or health care system or who may be hesitant to reach out on their own to make connections with others, a pattern noticed by three of the most senior spouses in this study.
Implications for Future Training and Practice
Both the military community and the mental health counseling profession are called to recognize the mental health struggles that military spouses face in order to help prevent suicide in this population. Military leadership should strategize ways to provide easier access to mental health services for spouses, including suicide prevention programs designed specifically for this population. In addition, suicide education programs for spouses may help them identify warning signs in others, ultimately strengthening the protective factor of the military spouse community. Military leadership should also work to reduce the stigma of receiving mental health services, not only for active-duty service members, but for their family members as well. Military leaders may likewise consider the participants’ suggestions regarding direct communication between military leadership and spouses, including a formalized check-in process for each duty station. Each of these suggestions offers a solution to the challenges outlined by both the professional literature and the spouse participants in this study regarding the mental health challenges faced by spouses and the risk factors of military spouse suicide.
Next, mental health counselors are called to be aware of and screen for the risk factors for suicide in the military spouse population that may be correlated to the inherent challenges that the military lifestyle brings. As prevention is a primary focus within the counseling profession (Sale et al., 2018), counselors might create preventative, psychoeducational groups for spouses to enhance their sense of connectedness and wellness. These groups would serve to identify spouses who may need additional supportive services to mitigate risk of depression and anxiety as well as other mental health issues. Additionally, when relocations occur, counselors should consider connecting their military spouse clients with mental health services in their new location and, with the permission of the client, reach out to those providers to ensure continuity of care. Finally, mental health counselors should actively seek out and build partnerships with military leadership in order to develop evidence-based resources specific to preventing suicide in the spouse population and to reduce the mental health stigma present in both active-duty service members and spouse communities.
Several limitations to this study exist related to the nature of qualitative methodology. First, in qualitative research, the researcher is the primary source of data collection and analysis. Thus, inherent biases exist throughout this data collection and analysis process (Anderson, 2010). However, bracketing and reflexivity reduced the potential impact of this limitation. Additionally, because mental health stigma exists within the military community, it is possible that participants were guarded during their interviews. Prolonged engagement assisted with mitigating this limitation. Finally, because of the nature of qualitative research, the sample size of the study is small (Atieno, 2009). For instance, the sample in this study did not include the perspectives of any male spouses or spouses who are African American or Hispanic. Additionally, although the sample includes Army, Navy, Air Force, and Coast Guard spouses, no Space Force or Marine Corps spouses are represented. Because of these limitations in gender, ethnicity, and branches, the sample is not representative of the military spouse community as a whole.
Implications for Future Research
Given these limitations of qualitative research, future quantitative research might focus on specific causes of suicide among military spouses. For example, studies might look at the characteristics of spouses who have committed suicide to detect any patterns or correlations that may exist. There should be particular focus on exploring any ethnic, racial, sexual minority, or gender identity disparities. Future researchers could pilot training programs in the military aimed at preventing military spouse suicide to develop best practices in this area. Finally, future qualitative studies should focus on the experiences of male military spouses. This is critical as the male military spouse suicide rate was recently found to be statistically higher than the overall male suicide rate in the U.S. population (40.9 per 100,000 and 28.4 per 100,000, respectively; DOD, 2020a).
Overall, the military spouses’ perceptions of risk factors for suicide in this study align with previous studies regarding military spouse mental health that have been conducted throughout the past 12 years. With a new knowledge of the number of spouses that are committing suicide, it is imperative that both the counseling profession and military leadership continue to work toward solutions for spousal mental health. These stakeholders are called to recognize the inherent risk factors of the military lifestyle and provide military spouses with the resources, training, and services that they need (and want) to address and prevent suicide within their community.
Disclosure and Disclaimer Statements
This research was partially funded by a faculty research grant from Arkansas State University.
The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense.
This research protocol was reviewed and approved by the Arkansas State University Institutional Review Board (IRB) in accordance with all applicable Federal regulations governing the protection of human subjects in research.
Neither the authors nor their family members have a financial interest in any commercial product, service, or organization providing financial support for this research.
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||Years as Spouse
What are your perceptions of suicide in the military spouse community?
What are the risk factors for suicide in the military spouse population?
What mental health challenges do military spouses face?
What resources currently exist to help prevent military spouse suicide?
What would you like to let the civilian world know about your life as a military spouse that they might not be aware of?
Is there anything else you would like to add?
Do you have anything else to add from our first interview?
What do you think causes military spouses to commit suicide?
What needs to be done to prevent suicide in the military spouse community?
What might be the consequences of not addressing suicide in the military spouse community?
What type of mental health support is most needed for the military spouse community?
How would your mental health differ, if at all, if you weren’t a military spouse?
Is there anything else you would like to add?
Follow-Up Email Questions
Is there anything else you would like to add to your interview responses?
What was it like for you to participate in this study?
What is the most important resource that military spouses need to prevent future suicides?
Rebekah F. Cole, PhD, NCC, LPC, is formerly an assistant professor at Arkansas State University and is now a research associate professor at the Uniformed Services University. Rebecca G. Cowan, PhD, NCC, BC-TMH, LPC, DCMHS, is a core faculty member at Walden University. Hayley Dunn is a graduate student at Arkansas State University. Taryn Lincoln is a graduate student at Arkansas State University. Correspondence may be addressed to Rebekah Cole, Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, 4301 Jones Bridge Rd., Bethesda, MD 20814, email@example.com.
Lisbeth A. Leagjeld, Phillip L. Waalkes, Maribeth F. Jorgensen
Researchers have frequently described rural women as invisible, yet at 28 million, they represent over half of the rural population in the United States. We conducted a transcendental phenomenological study using semi-structured interviews and artifacts to explore 12 Midwestern rural-based mental health counselors’ experiences counseling rural women through a feminist lens. Overall, we found eight themes organized under two main categories: (a) perceptions of work with rural women (e.g., counselors’ sense of purpose, a rural heritage, a lack of training for work with rural women, and the need for additional research); and (b) perceptions of rural women and mental health (e.g., challenges, resiliency, protective factors, and barriers to mental health services for rural women). We offer specific implications for counselors to address the unique mental health needs of rural women, including hearing their stories through their personal lenses and offering them opportunities for empowerment at their own pace.
Keywords: rural women, mental health counselors, feminist, perceptions, phenomenological
More than 28 million women, ages 18 and older, live in rural America and represent over half of the rural population in the United States (Bennett et al., 2013; U.S. Census Bureau, 2010). Researchers have discussed women’s issues as a distinct category within counseling for over 50 years, yet few counseling programs offer training specific to counseling women (American Psychological Association [APA], 2018; Broverman et al., 1970; Enns, 2017). Rural women have garnered even less attention within counseling literature and training over time (Bennett et al., 2013; Fifield & Oliver, 2016). In addition, rural mental health researchers have focused on rural populations in general, encapsulating women under the entire family unit (U.S. Department of Agriculture, 2015). However, in all environments, women experience mental health needs in unique ways (Mulder & Lambert, 2006; Wong, 2017). Although government agencies have increased efforts to alleviate mental health disparities in rural areas, there is limited research available on rural women’s mental health to guide these efforts (Carlton & Simmons, 2011; Hill et al., 2016). Thus, more studies focused on rural women can assist in comprehensive data-based decision-making efforts of federal, state, and local policymakers (Van Montfoort & Glasser, 2020). Mental health counselors who work with rural women have a unique perspective in understanding the needs of rural women and the disparities they face.
The Invisibility of Rural Women’s Mental Health
Researchers have described rural women as invisible within the mental health literature. Specifically, they have used words such as “unnoticed,” “lack of recognition,” “overlooked,” and “no voice and no choice,” which may illuminate why rural women have less access to appropriate mental health services and may underlie the noticeable absence of rural women as participants within research (Mulder & Lambert, 2006; Weeks et al., 2016). Members of rural communities have traditionally seen women as an extension of their nuclear and extended families and as responsible for involvement in community and church activities (Mulder & Lambert, 2006). Rural women, as a population with unique mental health needs, may need help (i.e., representation in research) getting their voices heard on a more macro level to promote systemic changes (Van Montfoort & Glasser, 2020). A research approach based in feminist theory may amplify the voices of rural women (Schwarz, 2017).
Feminism is a theoretical approach that evolved following the women’s movement in the 1960s, and grew to effect change in social, political, and cultural beliefs about women’s roles (Evans et al., 2005). Many of the early feminist writers spoke of women as “oppressed” and “having no voice” (Evans et al., 2005). Those words have been similarly found throughout the literature on rural women (Weeks et al., 2016). Feminist theory has traditionally challenged the status quo of the patriarchy by working to reduce the invisibility of women’s experiences (Evans et al., 2005; Schwarz, 2017). Further, feminist theory has evolved to amplify voices of all oppressed and marginalized individuals and to promote recognition of the intersectionality of identity. The feminist perspective can facilitate insight into the context of rural women’s experiences (Wong, 2017).
Challenges Faced by Rural Women
The definition of rural areas has historically been based on population size (U.S. Census Bureau, 2010). Some consider rurality a more accurate term than rural, as it may include population density, economic concerns, travel distances to providers, religion, agricultural heritage, behavioral norms, a shared history, and geographical location (Smalley & Warren, 2014). Rural women face unique needs related to the intersection of gender with race, ethnicity, age, and sexual orientation (Barefoot et al., 2015). Rural women have less access to educational opportunities, are often the head of household, and are more likely to live in poverty than urban women (Watson, 2019). Lesbian and bisexual rural women face challenges of bias, lack of support, and increased victimization (Barefoot et al., 2015). Although urban women also experience mental health issues related to motherhood, rural women often must travel long distances to services and have limited access to postpartum care (Radunovich et al., 2017). Residents in many rural communities experience food insecurity and related disordered eating with less proximity to grocery stores and limited food choices (Doudna et al., 2015). Isolation also creates a greater risk for partner abuse that is complicated by long distances to shelters, lack of anonymity, and a widely held view of traditional gender roles (Weeks et al., 2016). The lack of research regarding rural women and mental health compromises the efforts of rural counselors to provide care that is culturally responsive and efficacious (Imig, 2014). In addition, the recognized barriers of accessibility, availability, and acceptability of mental health services in rural areas disproportionally affect rural women (Radunovich et al., 2017).
Barriers to Mental Health Services
A lack of professionals, limited training for work in rural areas, high rates of turnover of mental health professionals, and limited research about rural demographics can negatively impact the quality of services (Smalley & Warren, 2014). In addition, rural residents may experience barriers such as long distances to services, adverse weather conditions, affordability of services, and a lack of insurance coverage (Smalley & Warren, 2014). Rural women may also feel reluctant to seek out mental health services for fear of loss of anonymity and the stigma attached to seeking mental health services in rural areas (Snell-Rood et al., 2019). Approximately 40% of rural residents with mental health issues opt to seek treatment from primary care physicians (PCPs), as these professionals may represent the only health care provider in the area (Snell-Rood et al., 2017). However, these professionals often have limited expertise in diagnosing and treating mental health issues (Hill et al., 2016).
Currently, the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) does not specify rurality or other cultural identities when referencing cultural competence within required curriculum. This omission may contribute to minimal specialized training, in addition to the limited research for mental health counselors to use as a guide for understanding the unique needs of rural women (Watson, 2019). Additionally, agencies have difficulty recruiting mental health counselors because of isolation from colleagues and supervisors, lower salaries, limited social and cultural opportunities, and few training opportunities specific to rural mental health (Fifield & Oliver, 2016).
Addressing Mental Health Needs of Rural Women
Given the limited research about rural women and their unique mental health needs, rural counselors are left with few evidence-based practices to utilize when working with this population (Imig, 2014). Historically, counseling researchers have equated “mentally healthy adults” with “mentally healthy adult males,” resulting in literature that is focused on best practices more appropriate for men (Broverman et al., 1970), and potentially upholding sex-role stereotypes within the fields of psychology, social work, medicine, and mental health counseling (APA, 2018; Schwarz, 2017). More recent researchers have demonstrated the efficacy of gender-specific counseling approaches (Enns, 2017). However, the approaches often do not consider the additional barriers to services that rural women may face, such as long distances to services, limited availability of mental health professionals, and the stigma of seeking services in a rural area (Hill et al., 2016).
In this transcendental phenomenological study, we sought to explore the lived experiences of licensed professional counselors (LPCs) who work with rural women in terms of their perceptions of rural Midwestern women’s mental health, and the academic training they received to prepare them for working with rural women. The study sought to answer the following research questions: (a) What are the lived experiences of LPCs who work with rural women?; (b) What are the challenges and benefits of working with rural women?; (c) How are mental health services perceived by those working with rural women?; and (d) What training, if any, did the participants receive that was specific to work with rural women?
Qualitative research, by its very nature, validates individuals who may be disempowered (Morrow, 2007; Ponterotto, 2010). Phenomenology is a qualitative method that helps researchers describe the common meaning of participants’ lived experiences specific to a particular phenomenon (Creswell & Poth, 2018). In this study, the phenomenon was the lived experiences of LPCs who worked with rural women. Transcendental phenomenology (Moustakas, 1994) provided a framework for the study that began with epoché, a process of bracketing the researchers’ experiences and biases, and the collection of participant stories (Creswell & Poth, 2018). For this study, postpositivist elements of transcendental phenomenology (e.g., bracketing and data analysis) were utilized to reduce researcher biases (Moustakas, 1994). Specifically, we viewed bracketing as essential because participants might not share the feminist viewpoint of the researchers. The infusion of feminism into the study came from a constructivist/interpretivist standpoint as I (i.e., first author and lead researcher) believed—based on literature—the stories of rural women were not being heard and, thus, designed the study to help illuminate the experiences, mental health needs, and resiliency of rural women (Morrow, 2007).
For this study, participants were recruited using criterion and snowball sampling. Criterion sampling involved selecting individuals on the basis of their shared experiences and their abilities to articulate those experiences (Heppner et al., 2016). Snowball sampling allowed for selecting participants who previously had a demonstrated interest in this area of research based on their connection to other participants. Criteria for participation included a degree from a CACREP-accredited counseling program, licensure within their jurisdiction, current practice, and clinical work that included rural women. To recruit participants, we collected names and emails from a Midwestern state counseling association; however, this method produced only two responses. So, we utilized snowball sampling by asking participants to refer us to others who met our eligibility criteria (Creswell & Poth, 2018). We determined the number of LPCs needed to describe the phenomena by achieving saturation of the data collected (Heppner et al., 2016). This saturation was reflected by eventual redundancy in participant responses.
Following approval from the appropriate IRB, an invitation to participate was emailed to potential participants and included a link to a demographic form and informed consent for those who met the criteria and wished to participate. Rural areas were defined as those geographic areas containing counties with populations of less than 50,000, a definition that did not include population density but was appropriate for the Midwestern areas included in the study (Smalley & Warren, 2014). Twelve mental health counselors met the eligibility criteria for participation and enrolled in the study.
All participants had graduated from a CACREP-accredited counseling program, were licensed to practice within their jurisdiction, were currently practicing privately or in an agency, and had a clinical caseload that included rural women. The designation of LPC was used throughout the study and included all levels of licensure within the various jurisdictions. All of the LPCs reported working with a wide variety of mental health issues; three of the LPCs had addiction counseling credentials. Eleven participants self-identified as female and one self-identified as non-binary. Eleven participants self-identified as Caucasian, and one self-identified as Native American. Years of experience working as a mental health professional ranged from 4 years to 27 years, with an average of approximately 12 years. All participants reported working with both urban and rural clients, and one participant listed a reservation as the primary location for her work. LPCs’ clients included adult rural women from the upper Midwest. The rural women were single or married with children, working or unemployed, Caucasian or Native American. In addition, all the participants expressed a connection to rural areas, either through personal experience of growing up in a rural area or through connections with extended family. Each participant chose a pseudonym that is referred to throughout the manuscript.
We collected data through individual semi-structured interviews and participant artifacts. The semi-structured interview format allowed for more collaboration and interaction between interviewer and interviewee (Creswell & Poth, 2018). In this way, the interview format aligned with a feminist research approach and helped eliminate a power differential between researcher and participant (Heppner et al., 2016). There were 12 interview questions aimed at exploring participants’ work with rural women, participants’ perceptions of the unique mental health needs of rural women, the influence of participants’ rural heritage on their work with rural women, challenges and benefits of participants’ work with rural women, and participants’ training specific to work with rural women (see Appendix for all 12 interview questions). As lead researcher, I conducted all 12 interviews in order to maximize consistency in employing the interview protocol while allowing participants to elaborate on responses. Interviews ranged from 30–45 minutes. All research documents, such as informed consents, demographic questionnaires, and transcriptions, were securely stored on a password-protected device.
Participants were invited to share artifacts that represented their work with rural women. Artifacts could include personal letters, poems, artwork, and photos (Heppner et al., 2016). The artifacts in this study provided an opportunity for broader expression of the counselors’ experiences as well as understanding their connection to rural life. Seven artifacts were pictures of objects or individuals that inspired participants’ work with rural women, two were stories about experiences of rural women, and one was an original poem entitled “Rural Woman.”
Brown and Gilligan’s (1992) research of young women and relationships utilized a Listener’s Guide for analyzing data. This guide is feminist and relational and allows researchers to pay attention to unheard voices. The Listening Guide is considered a psychological method that reflects the “social and cultural frameworks that affect what can and cannot be spoken or heard” (Gilligan & Eddy, 2017, p. 76). The method included three successive “listenings”—one for plot, one for “I” statements, and one for the individual in relationship to others (Brown & Gilligan, 1992). Throughout the listening process, I looked for and highlighted significant statements the participants made during the interview process that reflected the experiences of the phenomenon. I organized information via a phenomenological template under the heading “Essence of the Phenomenon” and included personal bracketing (epoché), significant statements, meaning units, and textural and structural descriptions (Creswell & Poth, 2018). Although a transcription service was utilized to transcribe the interviews, I read through the transcripts several times and coded data into categories or themes, which emerged organically from the transcripts. An independent peer reviewer then examined the transcriptions and helped to develop the codes and themes. We developed clusters of meaning from the significant statements into themes, followed by a textural and structural description that encompassed the significant statements and related themes. The rich and thick descriptions became the essence of the phenomenon enhanced by continual review of the interview tapes, journal notes, artifacts, and other data collected (Morrow, 2005).
The epoché section was written from my perspective as the primary researcher and first author. I was responsible for designing the study, collecting and analyzing data, and writing the manuscript. My co-authors served as consultants in designing the study and helped to write and edit the manuscript. As the primary researcher, I sought to see the lived experiences of participants from a perspective that was free from my assumptions (Creswell & Poth, 2018). I grew up in a Midwestern rural area, steeped in traditional gender roles, while witnessing significant change for all women in expectations and opportunities. During the process of the study, it became apparent that my perceptions of rural women as stay-at-home farmwives have changed to reflect a population more diverse in ethnicity, family structure, and socioeconomic status; however, the traditional patriarchal expectations have not changed. My work as a mental health professional shaped my desire to explore the perceptions of other LPCs’ experiences of their work with rural women. Prior to the data analysis, I bracketed my personal and professional rural experiences about power differentials within rural areas.
To promote trustworthiness, I utilized self-reflective journaling, member checks, the achievement of data saturation, independent peer review, and an external audit. I kept a journal and made notes throughout the data collection process to facilitate an awareness of biases and/or assumptions that emerged during the process (Heppner et al., 2016; Morrow, 2005). I also conducted member checks, asking all participants to review and provide feedback via email on descriptions or themes (Creswell & Poth, 2018; Morrow, 2005). Frequently, participants would elaborate on themes by adding clarification to their responses to the interview questions. The “prolonged interaction” (Ponterotto, 2010, p. 583) with participants was significant for developing an egalitarian and unbiased relationship between researcher and participant. This strategy was congruent with feminist theory because it acknowledged the subjectivity of the researcher within the study and facilitated a collaborative relationship between researcher and participant (Morrow, 2007).
Coding the data into categories or themes helped arrange the large amount of data that was collected. The process was made easier by taking notes, or “memoing,” when reading through the information. The peer reviewer evaluated potential researcher bias by checking the coding against all transcripts, serving as a “mirror” that reflected my responses to the research process (Morrow, 2005, p. 254). Next, we discussed possible themes that emerged from the data (Heppner et al., 2016). I also utilized an external auditor to aid in establishing confirmability of the results rather than objectivity (Morrow, 2005). The auditor examined the entire process and determined whether the data supported my interpretations (Creswell & Poth, 2018). Both individuals had participated in phenomenological research and were not authors of this article.
Analysis of the interview transcripts, the artifacts, and the journal reflections resulted in eight themes, organized into two categories. I further categorized each theme as: 1) textural, a subjective experience of the LPC’s experience with rural women; or 2) structural, the context of the experience. According to Moustakas (1994), the textural themes represent phenomenological reduction, a way of understanding that includes an external and internal experience; the structural themes represent imaginative variation, the context of the experience. One of the themes, counselor experience, fit the description of both textural and structural. The categories represented two distinct dimensions of the phenomenon: (a) LPCs’ perceptions of their work with rural women, and (b) LPCs’ perceptions of rural women and issues related to mental health.
Dimension 1: LPCs’ Perceptions of Their Work With Rural Women
Five textural themes emerged from the coding process; I took the names of three of these verbatim from the interviews. The textural themes included 20 codes that represented the subjective experiences of LPCs’ work with rural women. The participants’ pseudonyms were inserted into the direct quotes included in theme descriptions. Artifacts offered by participants were also included.
Rooted in the familiar saying of “pull yourself up by your bootstraps,” this theme included codes of resilient, stoic, self-sufficient, and independent. According to LPCs’ perceptions of rural women, bootstraps described an acceptance of the current conditions of rural life and a reliance on past experiences for guidance. Many of the LPCs believed that rural women came to counseling with a skill set that, as Nancy said, “can teach us and others about how to be resilient.” Fave commented that working with rural women also required patience:
It’s this sense of “I can do this.” There are more demands with farming, and rural women still believe they should be able to do it all. When they come into counseling it can be difficult because they have worked hard to sort of protect this thing and keep it close to them because they’re pretty sure they can figure it out themselves.
Courtney shared a story about a ranch woman who was grieving the loss of her husband and was struggling with family issues. She remarked in one session, “Today I decided it was time to put on my red cowboy boots.” For Courtney, this represented her client’s resiliency and stoicism—“I’ve got this, and I’ve got my red boots on to prove it.”
Trailblazer included pioneer, open-minded, resourceful, educated, and empowered; these words described LPCs’ perceptions of rural women’s abilities to move past accepting the realities of rural living and work toward change for improving themselves, their families, and their communities. According to the LPCs, this theme is distinct from bootstraps in that it is future-oriented rather than past-oriented. Elsie first referred to trailblazer when she told a story about a client who began recycling in the early 1980s: “She had bins and bins of recycling because she said, ‘I’m gonna leave this planet in a different shape than I found it.’ Rural women very much can be trailblazers.” The LPCs’ perceptions represented a new perspective that reflected resourceful change-makers, educated and empowered to challenge the status quo.
As one of her artifacts, Courtney offered a story about one woman’s determination to make Christmas special even though there were no resources for gifts and decorations. The woman found a large tumbleweed, covered it with lights and decorations, and declared it beautiful. Courtney said, “She was not just making do, but making things better.”
Challenges of Rural Women
LPCs observed multiple challenges for rural women including isolation, poverty/financial insecurity, role overload, grief, and generational trauma. Layla talked about the complex grief that was experienced by Native American women. She commented that “the death of a family member can mean losing someone from three or four generations. There is grief from loss of jobs, moving from the reservation, and loss of culture.” LPCs cited role overload as one of the most common experiences among rural women. Many rural women worked full-time jobs in addition to caring for family members while contributing to the farm/ranch operation. Jean observed that rural women “are responsible for everyone’s emotions in the family, sometimes leaving them isolated within the family.” LPCs believed that the isolation contributed to vulnerability. Rural women faced domestic violence, anxiety, depression, and addictions, exacerbated by having no one to talk with and long distances to services. Jean noted that resistance to change was perpetuated by the fear and control inherent in domestic abuse for many of her clients and led to complacency in reporting. The challenges of rural women described by participants defined the issues that LPCs faced when working in rural areas and increased their awareness of the critical needs of rural women.
Protective factors included a sense of identity and the strong support systems of families and community that gave rural women “a lot of people that you can draw upon to help you through hard times,” according to Nancy. Her clients valued the easy access to nature and the opportunity to “immerse yourself in something bigger than yourself. It’s a way to build resilience and find meaning and joy spending time outside.” Layla found a strong sense of identity evident in rural Native women as central to the ability to teach their children cultural beliefs—a protective factor for future generations.
Nancy shared a picture of a family moving their 100-year-old home to a new location as her artifact. Her description of the house and rural heritage symbolized part of what she believed was important for rural women—the connection to family and heritage along with a sense of purpose in maintaining family culture. She said, “It’s a good way to pass down the family stories and even the family culture.”
Counselor experience (textural) included the reasons why participants chose to become LPCs. These included the motivations that sustained their work and advice for new counselors. Assumptions about diversity, a sense of purpose, listening, and connections to resources encapsulated this theme.
Layla became a counselor because she wanted “to give back to my Native people.” Nancy believed that the work with rural women helped her build a rural counselor identity. Woods’ early experience with rural women felt profound because of the chaos she observed in the lives of her clients, many of them impoverished single mothers struggling to survive. She was given a sense of purpose in her work saying, “These women are burned into my head.”
When asked about advice for new counselors who anticipate working with rural women, participants offered the following brief statements:
“Don’t make assumptions.” (Courtney)
“Ask to be taught.” (Marie)
“Hear their story without filtering through your own personal lens.” (Nancy)
“There is a difference in working in rural areas—a conservative mind-set, practicality—and you need to meet people where they are.” (Kay)
“Listen more than you talk.” (Suzie)
“Have respect for their culture.” (Layla)
LPCs’ Perceptions of Rural Women and Issues Related to Mental Health
Three structural themes represented what Moustakas (1994) termed imaginative variation, the acknowledgment of the context of multiple perspectives. The themes were derived from nine codes that provided a vital aspect of further describing the phenomenon. The theme descriptions included participants’ quotes and artifacts.
Perceptions of Rural Heritage
This theme represented LPCs’ view of rural life, including traditional values, heritage, and expectations/perfectionism. According to participants, many of the rural women embraced the traditional values of their rural heritage, and the roles of rural life; this theme honors that perspective. Fave talked about the expectations that rural women often have of themselves: “It’s a perfectionist perspective, meaning they can do it all.” Even in light of the increased demands on rural women’s time and energy, Marie found that rural women were often hesitant to seek outside professional mental health counseling, choosing instead to rely on family and community.
Barriers to Mental Health Services
The barriers included codes of lack of resources, stigma, and invisibility. All LPCs felt concerned about the lack of resources for rural women. Suzie talked about the dearth of women’s shelters on the reservation and resources for women who are victims of domestic violence. Suzie said, “They often stay because there are no resources for them to leave, and they can’t afford it.” Woods noted the lack of daycare providers and the fact that many rural women cannot afford these services and depend on family members for childcare. According to several LPCs, rural women do not prioritize their mental health needs, possibly because of the many demands on them.
Kay and Marie practiced in an urban area but saw many rural women who chose to travel long distances for mental health services because it gave them a sense of anonymity. Kay said, “They know if their car is parked at the counselor’s office, it won’t be recognized by everyone in town.” Rural women also feared exposing family secrets if they disclosed something to a counselor who lived in the same area.
Poignantly, LPCs acknowledged the invisibility and minimization of rural women’s mental health needs. The following comments by participants exemplified the rural woman’s experiences of being unnoticed or dismissed. Elsie stated, “Even if rural women are speaking, they don’t have the platform like urban women do, and they feel like nobody gets this life.” Kay stated, “Everything is fine, everything’s great and we’re not going to talk about the fact that Grandma is crying all the time and wearing sunglasses.”
The statements of the participants provided powerful examples of the ramifications of the silencing imposed on rural women through traditional or cultural norms. The stigma of accessing mental health services created a loss of connection between the rural women who needed the services and their community. In addition, rural women often felt selfish in seeking services just for themselves. The consensus among LPCs was that rural women suffer to a greater extent than other rural populations because their needs are minimized or not recognized. Elsie remarked that rural women do not often see their stories in mainstream media, leading them to believe “I’m living this experience that nobody else lives.”
The description of the artifact contributed for this theme may further elucidate the invisibility of rural women. Woods’ artifact was a picture of two locally designed sculptures of women. Woods said, “They are so rooted and earthy.” One sculpture had no arms or legs and, for Woods, that “speaks to the limited access to needed supports and the lack of voice.”
Counselor experience (structural) described how LPCs provide mental health services to rural women and included connection to rural life, distances and dual relationships, and lack of academic training/postgraduate training. Although not all the participants grew up in rural areas, many had rural ties through extended family. Marie’s upbringing on a ranch influenced her understanding of rural women: “There is a more intense work ethic; women are very strong and independent and hardworking.”
The LPCs seemed to feel a strong sense of purpose in their work; some of them chose to become counselors and returned to their home communities to work. They discovered that the connections of shared experiences fostered trust in the counseling relationship and process. Most felt that they were helping to make positive change. Although all participants believed the connection to a rural heritage was critical in their work with rural women, some LPCs did not live and work in the same location, saying it helped to reduce the possibility of multiple relationships. Nancy commuted almost an hour to her work “because you really want to have the counseling relationship be through your therapeutic lens and not through the community lens.”
None of the participants recalled receiving academic training specific to rural areas; however, all participants agreed on the need for academic training focused on rural areas and rural women. Elsie believed that textbooks should “include women’s voices and rural voices.” Jean expressed her concern that “We don’t necessarily address rural women or what they need from the communities around them or even what their typical experience is. I think that’s a disservice to our counseling students.”
Two artifacts aligned with this theme: Marie’s picture of a young girl, dressed in overalls, pitching hay, and Mae’s great-grandmother’s writing desk (see Figure 1). Marie’s artifact exemplified the family’s connection to rural life and the physical strength of rural women that she observed in her work. Mae now uses the writing desk in her practice and feels it gives her a strong connection to her rural heritage.
Mae’s Great-Grandmother’s Writing Desk
Note. Mae presented this picture of her great-grandma’s writing desk when asked to provide
an artifact that demonstrated her work with rural women.
LPCs described rural women as strong, independent, resourceful, and resilient. However, this image of rural women was not corroborated within the research literature. An APA report on the behavioral health care needs of rural women (Mulder et al., 2000) did not mention resiliency as a coping strategy; however, in 2006, the report’s lead author recognized the need for additional research about resiliency in rural women, saying it would offer “significant potential benefit to rural women” (Mulder & Lambert, 2006, p. 15). In the present study, LPCs’ perceptions of rural women as resilient called attention to the innate strengths of rural women that developed out of necessity, cultivated by connections with family, community, and earth.
Rural heritage represented a dichotomy of rural tradition. From a positive perspective, participants believed the traditional roles of rural women provided a sense of identity and belonging. From a negative perspective, the traditional patriarchy evident in many rural areas dictated social and cultural norms, leaving rural women with the expectation that they should be able to “do it all.” Both perspectives defined a critical aspect of LPCs’ understanding of rural women. Even though many of the rural women participants described worked full-time to contribute to household income and health insurance (in addition to caretaker responsibilities), they faced gender inequities in income, employment, and educational opportunities (Watson, 2019). In addition, rural women have had little political power to effect needed policy changes for better access to care (Van Montfoort & Glasser, 2020).
LPCs highlighted multiple challenges that rural women experience: isolation, poverty, grief, role overload, and generational trauma. Barriers to obtaining services included stigma of mental health issues, loss of anonymity, a lack of resources, invisibility, and minimization of mental health issues. The general population also faces barriers of accessibility, acceptability, and availability of counseling services (Smalley & Warren, 2014); however, there were fewer references to the mental health barriers and challenges specific to rural women (Van Montfoort & Glasser, 2020). This is surprising given that the population of rural women exceeds that of any other population group in rural areas (Bennett et al., 2013). Rural women experience higher risks of depression, domestic violence, and poverty (Snell-Rood et al., 2019). The mental health services available in rural areas, often described as “loosely organized, of uneven quality, and low in resources” (Snell-Rood et al., 2019, p. 63), compound the challenges for rural women.
As evident in the themes of assumptions and diversity, rural women represent a unique population who deserve mental health services that reflect their specific needs. Rural communities and rural women are more diverse than once believed. LPCs’ observations are corroborated by research that acknowledged differences among rural women in socioeconomic status, family structure, age, sexual identity, ethnicity, education, and geographical location (Barefoot et al., 2015). In addition, there remains a misconception that the mental health needs of urban and rural women are the same; in fact, much of the literature about women and mental health is based on an urban context (Weaver & Gjesfjeld, 2014). The findings of the current study support the lack of recognition of the context of rural women’s issues and their status as an invisible population (Bender, 2016). Two LPCs’ observations of the isolation felt by rural women reinforced previous research of the invisibility of rural women. Elsie said, “Rural women don’t see their story a lot,” and Fave shared that “a lot of the women I work with don’t feel like they’re heard.”
None of the participants recalled academic training or postgraduate opportunities specific to work in rural areas or with rural women. Even though rural areas represent the largest population subgroup in the United States (Smalley & Warren, 2014), this study suggests that new counselors may not feel prepared to meet the needs of this underserved population. The shortage of mental health professionals working in rural areas and the lack of counselors who have training specific to rural mental health care suggest a need for rural-based training that might include an elective course in rural mental health and rural internships (Fifield & Oliver, 2016).
The recognition of the challenges and benefits of working with rural women may validate rural LPCs’ experiences, promote their professional identity as rural counselors, and potentially decrease the isolation felt when working in rural areas. Protective factors, including connections to family, community, and nature, may be critical for building resiliency in both rural women and rural LPCs. The increasing diversity of rural women is often contrary to the traditional stereotype of a stay-at-home farmwife (Carpenter-Song & Snell-Rood, 2017); diverse rural women may face unique barriers to accessing culturally relevant mental health services. In addition, many rural women experience role overload from working full-time and caring for families while contributing to the farm/ranch operation. Counselors should avoid interacting with rural women clients in ways that limit their identities based on stereotypes and work to make their services accessible for all women.
The study results also have implications for counselor educators. Rural-based counselors in this study did not report being taught how to work with rural women. A review of the 2016 CACREP programs found few gender-based counseling courses and none that addressed rural mental health. Programs could offer electives on counseling in rural areas, incorporate the context of gender and rural mental health into current curricula, and encourage rural internships. Collaborating with other rural health professionals may provide more informed approaches to working in rural areas. Rural residents may see their PCPs for mental health–related treatment, as PCPs may be the only health care provider in rural areas (Snell-Rood et al., 2017). Lloyd-Hazlett et al. (2020) suggested creating additional training for LPCs who choose to work in settings offering integrated care. Incorporating LPCs who have the appropriate training and skills into rural medical settings may offer mental health services in a familiar clinical context and one that does not broadcast engagement in mental health care. The collaboration may also provide more awareness of the mental health needs of rural women.
The study has several limitations. Although I took measures to reduce any personal bias as a non-traditional rural woman, I do not believe it is possible to eliminate all biases. Many of the participants talked about empowering rural women and working toward making their clients’ voices heard, both tenets of feminist theory (Evans et al., 2005); however, participants rarely used the language of feminism. Several of the participants related personal stories of their connections with rurality and, often, their stories of rural women were from decades ago. Their stories may not have represented the current generation of rural women. Another limitation relates to the demographics of LPCs because a majority of participants self-identified as Caucasian and female and represented rural areas in the Midwest. LPCs working in other areas of the United States may encounter different demographics of rural women, mental health challenges specific to region, and unique intersections of their clients’ identities. Finally, the experiences of rural women were heard through LPCs and not from rural women clients themselves.
Directions for Future Research
This study included a sample of rural LPCs who were primarily Caucasian females from the Midwestern United States; future researchers may seek professional perspectives from participants who represent a blend of race, ethnicities, gender identities, and geographical locations. Research with rural women as participants themselves is also an important opportunity. Based on findings from this study, future researchers might also explore training needs related to work with rural women and rural populations. Studying counselor educators who teach in counseling programs based in rural areas could also offer unique insights. This may reveal information about ways educators currently infuse rural culture and work with rural women into the curriculum. Future researchers may study counselors, health care providers, and rural women in finding ways to integrate health care services in rural areas to provide better access to services and reduce the stigma often associated with mental health. Finally, additional studies about working with rural PCPs may highlight issues (e.g., intimate partner violence) that could benefit from early screening of symptoms.
Gilligan offers these words: “To have something to say is to be a person. But speaking depends on listening and being heard; it is an intensely relational act” (1982/1993, p. xvi). As indicated in our findings, rural women are too often invisible and unheard. This study represents a first step in amplifying the voices of rural women regarding their specific mental health needs. The experiences of the LPCs in this study have illuminated ways to connect with rural women, listen to their stories, and validate unique aspects of their cultural identities that seem to be well illustrated in one participant’s poem:
Resilient; stubborn; motivated
frightened; broken; courageous
Struggling; down-trodden; strong
Relentless in self-expectation
Armed with determination.
A common thread unites us
The heart gently calls, and the
soul asks only—please—listen to me.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Twelve Interview Questions
- Tell me about what comes to mind when you think about working with rural women.
- Tell me about where you grew up and how that has influenced your work with rural women.
- Tell me about how you began your work with rural women.
- What have you learned about rural women through your work with them?
- What are the unique mental health needs of rural women that you have seen in your work?
- Tell me about some of the benefits and rewards, if any, you have experienced working with rural women.
- Tell me about some of the challenges, if any, you have experienced working with rural women.
- How have your experiences working with rural women changed you as a mental health counselor?
- Tell me about any academic/classroom experiences in your graduate program that involved the mental health issues of rural women (e.g., class discussions, special projects, conversations with colleagues, internship experiences).
- Tell me about any training experience post-graduation that have involved the mental health issues of rural women (e.g., workshops, conference presentations, webinars, conversations with colleagues).
- What would you like other counselors to know about working with rural women?
- Please describe how the artifact that you have chosen relates to your work with rural women.
Lisbeth A. Leagjeld, PhD, NCC, LCPC, LPC-MH, is a program liaison and faculty member at South Dakota State University – Rapid City. Phillip L. Waalkes, PhD, NCC, ACS, is an assistant professor and doctoral program coordinator at the University of Missouri – St. Louis. Maribeth F. Jorgensen, PhD, NCC, LPC, LMHC, LIMHP, is an assistant professor at Central Washington University. Correspondence may be addressed to Lisbeth A. Leagjeld, 4300 Cheyenne Blvd., Rapid City, SD 57709, Lisbeth.firstname.lastname@example.org.
Brenda Freeman, Tricia Woodliff, Mona Martinez
In addition to developing teaching, clinical supervision, and research skills, new entrants into the counselor education workplace will also face the challenging responsibility of gatekeeping. Gatekeeping can be both anxiety-provoking and time-intensive for new faculty members. To enhance the confidence and competence of new entrants into counselor education faculty positions, strong doctoral preparation in gatekeeping is critical. In this article, the authors describe a developmental experiential model to infuse gatekeeping instruction into counselor education and supervision doctoral courses. The model includes six experiential gatekeeping modules designed for instruction at three developmental levels. A phenomenological qualitative study of the model was conducted, leading to the discovery of four themes: importance of gatekeeping, behind the curtain, understandings vary by developmental level, and uneven responses to experiential learning. Developmental, pedagogical, and administrative implications for counselor educators are discussed.
Keywords: counselor education, gatekeeping, doctoral preparation, experiential model, phenomenological
For new entrants into the counselor education higher education workplace, involvement in gatekeeping can be unavoidable and challenging. Although direct gatekeeping responsibilities may be conducted by associate and full professors in many institutions (Schuermann et al., 2018), assistant professors often teach courses in which gatekeeping issues arise. Evidence suggests that faculty perceptions of gatekeeping differ by academic rank (Schuermann et al., 2018), with untenured professors reporting greater concerns about gatekeeping than tenured faculty (Gaubatz & Vera, 2002). Bodner (2012) asserted that “faculty and supervisors may receive little guidance on how to implement such [gatekeeping] procedures in a highly ethical manner and/or how to approach complex and challenging gatekeeping dilemmas” (p. 60).
The gatekeeping role is taught during doctoral preparation. In the doctoral standards set by the Council for Accreditation of Counseling and Related Educational Programs (CACREP), Section B (Doctoral Professional Identity) requires the instruction of students in five core areas, two of which (teaching and supervision) include gatekeeping standards (CACREP, 2015). Supervision standard 2.i. requires programs to include in the curriculum “evaluation, remediation, and gatekeeping in clinical supervision” (CACREP, 2015, p. 35). Teaching standard 3.f. states that the curriculum must include “screening, remediation, and gatekeeping functions relevant to teaching” (CACREP, 2015, p. 36). The inclusion of gatekeeping in CACREP standards signals the importance of providing doctoral students with the knowledge, skills, and experiences necessary for them to be effective in their future role as gatekeepers.
There is a dearth of literature on pedagogy for teaching gatekeeping to doctoral students. Barrio Minton et al. (2018) conducted an analysis of select published articles and concluded that there has been a lack of focus on doctoral-level counselor education preparation. With limited publications centered on doctoral preparation and a generally minimal focus on pedagogy, the instructional approaches to prepare doctoral students for gatekeeping are largely unknown.
The purpose of our study was to design and deliver a developmental experiential model for increasing doctoral student competence in gatekeeping and to examine student reactions to these learning experiences. We have titled the gatekeeping instructional approach the Developmental Experiential Gatekeeping (DEG) Model. The DEG Model was designed and implemented at one CACREP-accredited counselor education and supervision (CES) doctoral program in the Western United States with a focus on preparing students for academic positions. This article presents the results of a phenomenological qualitative study of the experiences and reactions of doctoral students to the DEG Model. The insights gleaned from the study are discussed from the standpoint of improving pedagogy for gatekeeping instruction. The rationale for the study was that gatekeeping is a challenging aspect of counselor education teaching and supervision roles, particularly for new entrants into academia. Effective preparation in gatekeeping practices may not decrease the strain of dealing with difficult student remediation, suspension, and potential legal issues, but preparation is necessary to bolster strong gatekeeping and remediation practices.
Developmental Framework With Experiential Pedagogy
The DEG Model is an approach to instructing doctoral students in gatekeeping through the delivery of six curricular units divided into three developmental levels. The model was developed and implemented at a midsize institution (classified in the Carnegie system as an R1: Doctoral University – Very High Research Activity) with three counseling master’s programs and a doctoral program in counselor education and supervision located in the Western region of the United States. All programs were fully accredited under the CACREP 2016 standards (CACREP, 2015).
The DEG Model is grounded in both developmental and experiential pedagogy. The developmental framework, based in cognitive developmental theory, endorses sequential movement in learning processes within an established hierarchy (Bloom, 1956; Loevinger, 1976; Piaget, 1977). Higher levels are not attained without first accomplishing less complex levels of cognitive understanding. The development of formal operations, in which more sophisticated connections and abstract concepts are understood, is gradual and is based upon the interaction between cognition and experiences (Case et al., 2001; Eggen & Kauchak, 2001). Formal operations are situation specific (Eggen & Kauchak, 2001). Students may have reached formal operations in learning domains where they have a supporting framework of experiences, such as in post-internship counseling skills, and yet not function in formal operations in other content domain areas (such as research skills).
The experiential learning approach, reportedly a more powerful pedagogy than didactic instruction alone (Borowy & McGuire, 1983; Shreeve, 2008), is focused on gaining knowledge through direct experience. The process typically begins with preparation for the experience, followed by engaging in the experience, and culminating with reflection or testing of observations (Galizzi, 2014; Kolb & Kolb, 2009). Positive outcomes associated with experiential pedagogy include increased student engagement in the learning processes, improvements in cognitive functioning, greater acquisition of knowledge across a variety of subject areas (Galizzi, 2014; Greene et al., 2014; Tretinjak & Riggs, 2008), increases in historical empathy, improved critical thinking, and greater cultural open-mindedness (Greene et al., 2014). Borders et al. (1996) found didactic and experiential practices were related to a significant increase in student self-appraisal of supervision capacity. It is reasonable to assume that because experiential activities in supervision led to greater student competence, experiential activities in gatekeeping may also lead to greater student competence.
Research supports that experiential learning is an efficacious approach to teaching multicultural counseling (Kim & Lyons, 2003), particularly when the experiences closely emulate real world applications (Furr & Carroll, 2003; Granello, 2000). Although research on experiential learning related to teaching gatekeeping was not found, experiential learning in gatekeeping may be similar to multicultural counseling in that the experiential activities often used in the instruction of multiculturalism may be unfamiliar or uncomfortable for students. The DEG activities were unfamiliar experiences for doctoral students. Also parallel to instruction in multiculturalism, there is a gatekeeping culture that is unfamiliar to most doctoral students. Students must be introduced to the culture of gatekeeping, including the cultural norms and the development of a gatekeeping mindset.
Two assumptions were foundational to the pedagogy of the DEG Model. First, the authors assumed the DEG Model would have greater impact on student learning if delivered over more than one semester to allow time for integration of knowledge. Second, to maximize the advantages of experiential pedagogy, we assumed each DEG module should provide students with the opportunity for reflection after every experiential activity.
The DEG Model
The DEG Model was structured through a hierarchy informed by developmental principles (Bloom, 1956). Level 1 modules designed to meet the overall learning goal, To increase student understanding of concrete knowledge related to gatekeeping, dispositional assessment, and admissions, were delivered in a first-semester, first-year doctoral seminar course. Although experiential assignments were included with each module, the focus in Level 1 was on student acquisition of concrete knowledge (Bloom, 1956). The modules in Level 2 were integrated into an introductory course in clinical supervision and were designed to address Bloom’s Taxonomy (1956) comprehension and application levels. The learning goal for the Level 2 modules was To increase student knowledge and applied skills related to remediation and gatekeeping in clinical supervision. The Level 3 modules, designed to be consistent with Bloom’s Taxonomy (1956) analysis and synthesis levels, were infused into Doctoral Seminar II, a course with a focus on teaching pedagogy. The modules were designed toward the following goal: To develop student skills in analysis and synthesis of knowledge related to gatekeeping, with a focus on developing a systems understanding of gatekeeping. Each module described in the next section incorporated an experiential element and a written reflection.
The specific content domains for each module were driven by the literature. Table 1 includes descriptive material on the content for each module. The overall design of the DEG Model involved the infusion of six gatekeeping modules over a 16-month time frame in three sequential CES doctoral courses.
DEG Modules: Developmental Level, Content Domains, and Source Material
||Examples of Source Materiala
|Level 1, Module 1
||Grappling With Gatekeeping Through Dialogue
||Purposes and processes of gatekeeping; rationale for gatekeeping; ethics in gatekeeping; licensure boards and accreditation bodies and gatekeeping
||Bodner, 2012; Brown, 2013; American Counseling Association, 2014; Council for the Accreditation of Counseling and Related Educational Programs, 2015; Lumadue & Duffey, 1999
|Level 1, Module 2
||Professional Fit and the Prevention of Future Adversity: Dispositional Assessment in Admissions
||Admissions procedures in counselor education; suitability and dispositional assessment; impairment and problematic dispositional behaviors; dispositional assessment approaches
||Elpers & FitzGerald, 2013; Swank & Smith-Adcock, 2013; Winograd & Tryon, 2009; Brear et al., 2008; Tate et al., 2014; Reddy & Andrade, 2010; Taub et al., 2011; Swank et al., 2012; McCaughan & Hill, 2015
|Level 2, Module 1
||Gatekeeping Issues in Clinical Supervision Through the Lens of the Discrimination Model
||Supervisor roles in gatekeeping; giving feedback to supervisees; evaluation of supervisees; discrimination model
|Association for Counselor Education and Supervision Taskforce on Best Practices in Clinical Supervision, 2011; Swank, 2014; Gazzola et al., 2013; Gizara & Forrest, 2004; Miller, 2010; Bernard, 2006; Bhat, 2005
|Level 2, Module 2
||Mentoring Students Through Monitoring Remediation
||Designing and monitoring remediation plans
||Dufrene & Henderson, 2009; Henderson, 2010; Kress & Protivnak, 2009; Lamb et al., 1987; McAdams et al., 2007; McDaniel, 2007; Russell & Peterson, 2003; Bemak et al., 1999; Crawford & Gilroy, 2013; Russell et al., 2007
|Level 3, Module 1
||Gatekeeping Through a Systems Lens: Designing an Ecological Gatekeeping Map
||Ecological model and gatekeeping; collaboration and teaming in gatekeeping; shadow organization; higher education culture
||Forrest et al., 2008; Johnson et al., 2008; Jacobs et al., 2011; Goodrich & Shin, 2013
|Level 3, Module 2
||The End of the Road: Gatekeeping and Heartbreaking Adversity
||Legal issues in gatekeeping; due process; working with legal counsel; documentation; managing grievances
||Brown-Rice, 2012; Elpers & FitzGerald, 2013; Enochs & Etzbach, 2004; Forrest et al., 1999; Frame & Stevens-Smith, 1995; Homrich, 2009; Hutchens et al., 2013; Kerl et al., 2002; McAdams et al., 2007
aSource materials appear in order of recommended reading.
Grappling With Gatekeeping in Level 1, Module 1
In this module, for three consecutive classes (9 clock hours), first-year students were required to read and discuss journal articles on foundational gatekeeping topics selected by second-year students with guidance from the instructor. The structured class instruction and discussions on the readings were facilitated by the second-year students. The experiential component for first-year students was engagement in structured dialogue. The experiential component for second-year students was teaching gatekeeping and leading discursive discussion with first-year students under live faculty supervision. Students then reflected on the process.
Dispositional Assessment in Admissions in Level 1, Module 2
Armed with background knowledge from Module 1, students participated in the dispositional assessment training video for the Professional Disposition Competence Assessments—Revised Admissions (PDCA-RA; Freeman & Garner, 2020; Garner et al., 2020). The training video entails participant ratings of dispositions during admissions interview clips without training, followed by training in the assessment process, post-training rating of interview clips, and instructions on use of the PDCA-RA in actual admissions interviews. Following the PDCA-RA training, the doctoral students co-interviewed (with CES faculty) the master’s program applicants, using the PDCA-RA as the admissions dispositional assessment tool. This was followed by written reflections about the experience.
Gatekeeping Issues in Clinical Supervision in Level 2, Module 1
This module was preceded by several weeks of instruction in clinical supervision theory and the assignment of one master’s-level supervisee to each doctoral student. Midway through the semester, students were instructed in best practices for giving evaluative formative and summative feedback in clinical supervision through the lens of the discrimination model (Bernard, 1997). The experiential component of this module consisted of students being required to deliver either formative or summative (positive or corrective) evaluative feedback to clinical supervisees related to the expected student dispositions under faculty supervision. Students then reflected on the process.
Mentoring Students Through Monitoring Remediation in Level 2, Module 2
This module was designed to provide doctoral students with an experiential opportunity to partner with faculty in providing support for master’s students working on mild remediation issues. Examples of mild remediation issues included problems with class attendance or punctuality, difficulty adjusting to the professional expectations of graduate school, and challenges with interpersonal relationships in the classroom. The faculty team working in concert with the master’s student needing remediation determined the nature of the specified growth experiences for the master’s student. The doctoral students then implemented structured processes to support the remediation process, such as facilitating a reflective process on a student’s effort to become more culturally sensitive or serving as an accountability partner for a student working to become more conscientious. Doctoral students were not involved in working with any students where dismissal was a likely outcome. Doctoral students then wrote journal reflections on the experience.
The Ecological Gatekeeping Map in Level 3, Module 1
With the developmental goal of synthesizing complex knowledge, students were tasked with creating an ecological gatekeeping map. The process began with didactic instruction in Bronfenbrenner’s (1977) ecological systems theory, followed by discussions of microsystems, mesosystems, exosystems, and macrosystems in higher education. The goal was to assist students in acquiring a systems perspective on gatekeeping, including subsystem interactions that influence the feasibility and outcomes of remediation, suspension, and dismissal of counseling students. As part of the module, students were introduced to the concept of the shadow organization (Allen & Pilnick, 1973). Allen and Pilnick (1973) described organizations as having two organizational structures—one being the visible structure obvious in the university organizational chart and the other (the shadow organization) consisting of the unwritten cultural expectations and daily behaviors of the institution. An example of the shadow organization influencing gatekeeping would be if the counseling handbook states that the program gatekeeps, but there is an unwritten culture in which the administration will not allow the program to dismiss even the most unethical student. Working as a team, the students had 6 weeks to interview administrators and faculty, collect policy and procedure documents, read and apply relevant literature, and prepare a group presentation of a visual ecological gatekeeping map.
Gatekeeping and Heartbreaking Adversity in Level 3, Module 2
The final DEG module began with assigned readings of gatekeeping legal cases. Students were then charged with the responsibility to create a non-academic dismissal scenario, write and compile all documentation, and prepare to dramatize the scenario through a mock dismissal hearing. Roles adopted by students for the mock hearing included the fictitious master’s counseling student, the faculty member central to the dismissal scenario, the department chair, and the college dean. The mock hearing was enacted and was judged in real time by a university attorney and a university administrator (a dean or provost). Immediately following the hearing, the judges processed the hearing with the students, offering legal and procedural corrections. Students then reflected on the experience.
The question “What are the lived experiences of doctoral students as they engage in gatekeeping instruction?” was addressed through qualitative methodology. Because we were interested in the subjective experiences of the student learners, the qualitative study was conducted using a phenomenological approach (Creswell, 2013; Moustakas, 1994). Investigation through deep exploration of lived experiences is part of the phenomenological paradigm (Creswell, 2014). Deep exploration of lived experiences with the gatekeeping experiential activities was congruent with the goal of understanding the journey of doctoral students to capture the essential meanings of gatekeeping. Husserl (2001) postulated that it was possible for researchers to bracket their own experiences to capture the essence of the experiences of others, which was one of the objectives in this analysis. The ontological assumption, informed by the constructivist paradigm, was that socially constructed multiple realities of gatekeeping exist (Mertens & Wilson, 2012).
The study was primarily conducted as scholarly inquiry into the developing professional identity of doctoral students relevant to the gatekeeping role. Aligned with the research question, the data analysis was accomplished through a phenomenological tradition, with a primary goal of revealing rich and concrete descriptions of the learning process and the translation of formal and experiential instruction into professional identity.
Subsequent to the analysis, the findings were also used to inform program development and pedagogy for counselor educators. This secondary use of the findings to inform program improvement is aligned with the values branch of program evaluation in which participant responses to program experiences are often viewed through a qualitative, constructivist perspective (Abma & Widdershoven, 2008). The use of the findings to inform counselor education pedagogy did not influence the interview protocol, data collection, or analysis process, which were conducted utilizing the phenomenological approach.
For phenomenological studies, Creswell (2013) recommends between 3 and 15 participants. At the point of data collection, there were 12 students enrolled in the CACREP-accredited counselor education and supervision doctoral program where the DEG modules were delivered. The doctoral program was housed in the College of Education at a midsize university, classified in the Carnegie system as an R1: Doctoral University – Very High Research Activity.
Each of the 12 potential doctoral student participants had experienced some or all of the DEG modules, allowing the research team to gain insights from different levels of doctoral student professional identity development. Two students were removed from the participant pool because of a conflict of interest, yielding a participant pool of 10 students. Following human subjects research review board (IRB) approval, the 10 potential participants were contacted by email and invited to participate in the study. All 10 consented to be interviewed; however, one student was unavailable during the data collection window, leaving nine study participants.
As a precaution to mask the identity of the participants, specific demographics are not reported in this article. In general terms, the participants were primarily self-reported females, predominantly White, and ranged between 24 and 39 years old. Educationally, all participants had earned master’s degrees in counseling prior to entering the doctoral program. The students earned their counseling master’s degrees in institutions located in the West, South, Southwest, East, Midwest, and Rocky Mountain regions.
All nine doctoral student participants agreed to be interviewed and to allow electronic recording. Face-to-face interviews ranging in length from 30 to 60 minutes were conducted by a single member of the research team. No incentives were offered. Participants were informed that they could skip any of the interviewer questions. The items for the semi-structured interview protocol were first written by the lead author and then piloted with the second and third authors. The final items were determined by consensus of the research team. The interview protocol included nine items. Three were global items such as “Describe your learning experiences with gatekeeping and remediation in counselor education.” Of the remaining six items, each was dedicated to one of the DEG units. The interviewer first asked the student if they recalled having participated in the specific unit, followed by the prompt: “Please describe your experience with this unit. What was that learning experience like for you?” The same question was repeated for each of the six units.
Although the DEG Model was part of required coursework, participation in the study was strictly voluntary. To protect student participants from social pressure to participate in the study, all communications with participants were initiated by a single member of the research team with no evaluative relationship to the students. Further, the interviews were conducted during a time frame when no participants were enrolled in courses instructed by any member of the research team.
As a second source of data, student reflections were collected at the end of each unit. The reflections were ungraded and were used in the study to triangulate the interview data for the purpose of considering the consistency between the interview data and the reflections, part of the establishment of trustworthiness. The reflection data consisted of written, open-ended reflections on the experiences of students with each of the DEG modules. The reflections were submitted immediately following the experience with each DEG module. To scaffold the reflection process for students who found unstructured, open-ended reflections challenging, three prompts were offered: “Please share your reactions to the learning experience you engaged in today.” “What did you learn today that you consider to be important to your understanding of gatekeeping and remediation?” and “What questions come to mind as a result of engaging in this learning experience?”
The overarching purpose of the data analysis process is to bring structure and order into understanding the data for the purpose of addressing the research questions (Patton, 2015). In phenomenological research, there are many paradigms and differing worldviews on data analysis, including the issue of whether it is most suitable to analyze participant narratives through an ideographical approach or amass the data into qualitative themes (Moules et al., 2015). Accumulation of data with an analysis of themes was selected as the phenomenological data analysis approach. The results of the study were analyzed through Creswell’s (2014) approach to phenomenological analysis. Throughout the analysis, the research team bracketed their presuppositions and assumptions. The purpose of bracketing was to allow the voices of the participants, not the researchers, to dominate the analysis.
Following the interviews, the recordings were transcribed (using pseudonyms), and the transcriptions were reviewed for accuracy. The analyses of both the interviews and the reflections were conducted using NVivo12 (QSR International). The interview analysis was a three-part process that included open coding, thematic analysis, and thematic integration (Rossman & Rallis, 1998). The process began with reading and rereading the transcripts to deduce a list of core meanings for each transcript. This work was conducted by the lead author and verified by independent analysis of the second author. Once core meanings of individual transcripts were agreed upon, the meanings were cross-analyzed for repetition and clustered into themes and subthemes by the first and second authors working independently of one another. Team consensus was reached, and the data were then organized into a codebook. Data saturation was accomplished when it was determined that no new themes were emerging. The themes were then reviewed in relation to one another to clarify overlapping areas and collapse subthemes into broader themes. Direct quotes were extracted to support both textural and structural descriptions. After the analysis of the interview data, student reflections were analyzed using the codebook derived from the interview data. An “inconsistent” codebook category was created to code data inconsistent with the data found in the interviews. An “other coding” category was created to code data that reflected new concepts or themes not apparent in the interview data.
An important aspect of considering trustworthiness in phenomenological research is addressing bias (Creswell, 2013). The research team consisted of two White female researchers and one Hispanic and American Indian female researcher. One was a tenured full professor with extensive CES experience. Another had conducted research related to dispositional assessment. The third member of the research team had no specific background or personal experiences with gatekeeping. The team members had a wide range of experience in program evaluation and qualitative research. The shared assumptions of the research team were that understanding gatekeeping was an important professional obligation and that doctoral students with career aspirations of entering counselor education needed a solid foundation in gatekeeping.
The process of establishing trustworthiness began with an understanding that the findings represented only one of many interpretations of the data (Corbin & Strauss, 2008). Early in the process, we consulted with a qualitative research expert who confirmed the analysis process (D. Barone, personal communication, December 2, 2018). Peer debriefing was used throughout the process (Creswell, 2014). The debriefing process included the research team presenting tentative findings at one regional and one national counselor education conference, a process that fostered research team deliberation on the interpretation of the data.
The areas for bracketing were identified prior to the interviews and consisted primarily of the delineation of the presuppositions and assumptions of the research team in order to avoid hindering the capacity of the team to listen to the participants. The actual bracketing was performed during the analysis stage by making notations of areas where presuppositions and assumptions might influence interpretation. Participants were not asked to bracket their assumptions. Direct quotes were heavily relied upon in the analysis to assure that the voices of the participants were heard throughout the process. An expert reviewer, a counselor educator not involved in the study, audited the results (Creswell, 2014; Patton, 2015), providing the team with feedback. Last, member checking was used to ascertain that we had not misunderstood or used participant statements out of context.
The analysis yielded four themes: importance of gatekeeping, behind the curtain, understandings vary by developmental level, and uneven responses to experiential learning. Pseudonyms used during data collection were replaced with participant numbers for reporting purposes.
Importance of Gatekeeping
The theme importance of gatekeeping describes the valuing of gatekeeping, remediation, and dispositional assessment by participants. Across all participants, gatekeeping and related processes were perceived as critically important. The rationale for valuing gatekeeping varied from participant to participant, with most offering more than one justification. Five participants positioned their responses within the professional mandate to protect the public. P1 stated:
I learned that some of my experiences as a counselor really influenced the importance that I put on gatekeeping . . . I’ve been doing counseling . . . so I had exposure to what it looks like when counselors in the field aren’t well suited or act from their own personal needs.
Two participants reflected that the protection of the public was particularly important because of the attraction of emotionally wounded individuals to the profession. As stated by P2:
[Gatekeeping and remediation] . . . are extremely important because people oftentimes I find go into the counseling field for the wrong reasons. Whether it’s a personal history with mental health issues and they’re trying to solve their own issues or because. . . maybe they like the power differential that is created in a helping relationship . . . they want to somehow take advantage.
Protecting counseling programs, universities, and the profession was also expressed as a reason for valuing gatekeeping. P3 stated: “The counseling profession is our own and needs to be protected,” later adding, “Despite how difficult it can be, if warranted, I want to play hardball to protect my students, other faculty, alumni, program, and the profession.”
Behind the Curtain
Eight of the nine participants reported that they had limited awareness of gatekeeping and related processes in their master’s programs. P4 stated: “I mean, I’m sure we were gate checked in my master’s program, but I don’t really remember anything about it.” Participants discussed the process of learning about gatekeeping after the experience of being unaware of it in their master’s programs, noting that this process gave them a glimpse of what goes on behind the curtain. P9 described it as being given a different seat in the house, stating:
In my master’s program, I didn’t have any knowledge of anything like this . . . but now in my first year of the doctoral program, I feel like I have so much more of an understanding and kind of . . . like a different seat in the house. I can see how it all works and the importance of it.
Feelings associated with peeking behind the curtain were varied. P3 described it with positive affect: “So the first seminar class was really helpful. It was very much like the Wizard of Oz, pulling the curtain back and seeing what goes on behind everything in higher education.” P4 reported it to be an unsettling experience: “So our first year when we were learning about it, it was still a bit mysterious . . . kind of scary . . . I didn’t really know this process was going on . . . not like, so overtly. . . . it was kind of like, oh my God.”
Understandings Vary by Developmental Level
All participant interviews reflected the theme understandings vary by developmental level. Some participants overtly addressed changes in developmental understandings, like P3, who said simply: “I thought it was tricky until it wasn’t.” She described her journey as becoming more comfortable over time. P5 reported: “I think the scaffolding was appropriate. . . . more content focused initially and then more at the process level with the application piece later on. It wasn’t like we were jumping right into applicability before we actually understood the different concepts.”
From the standpoint of developmental level, Level 1 students like P6 were inclined toward a concrete understanding of the concepts: “So my understanding of gatekeeping and counselor education is that it’s a process to make sure that the counseling students are where they’re supposed to be . . . academically and emotionally.” More advanced students like P1 reflected greater complexity in their understandings:
So part of our responsibility as counselors is to make sure the field is engaging ethically, and if we’re allowing people that are wounded in such a way that they’re not able to engage productively as counselors, then as a profession we’re acting essentially unethically. . . . Counseling is fundamentally about the person of the counselor and so we have to take that into account as counselor educators . . . gatekeeping or remediation become a big part of the more nebulous component of what makes a good counselor.
Another developmental issue was that the experiential frame or voice reflected by the participants varied throughout the process. Sometimes, particularly but not exclusively early in the developmental process, participants spoke with a student voice. At other points, participants reflected on their experiences through the perspectives of a clinical supervisor or counselor educator, reflecting a faculty voice. Sometimes participants shifted between the two voices. P5 directly addressed this issue:
So each of us was going through the process of being evaluated because there was a gatekeeping process for us as doctoral students . . . and so knowing that that was happening for us at the same time we were teaching it . . . it was just a pretty complex process.
P4’s comment on learning to give direct feedback in the clinical supervision unit reflects a conflicted voice:
But with a supervisee, it was different because you’re also in this evaluative role. . . . I wanted to like, be really supportive, you know . . . [but] I also had to evaluate their work. I wanted to be direct, but I also don’t want to give them a bad evaluation. It was just very difficult.
In this statement regarding the Level 1 module, P8 spoke through a counselor educator perspective:
I’m thinking about potentially becoming a faculty member . . . in interviewing at universities, I’d like to really try to understand their philosophy of gatekeeping and remediation to see if it could, like, be a good fit for me. If I went to a school and found out they didn’t do gatekeeping, I would have a really hard time being there . . . it’s just kind of like, “Well, what are we doing to ensure that the people we’re serving are protected?”
Uneven Responses to Experiential Learning
Across all nine interviews, participants indicated a strong, positive response to experiential learning. However, some experiential elements were more powerful than others. Reflecting on the experience of participating in the PDCA-RA training video and the master’s admissions interviews, P7 stated: “I think it was just really, really fun to be a part of the training . . . and then to actually get the chance to do it again during admissions.” Teaching gatekeeping was described as a positive experience by P4:
Being forced to teach anyone anything is a good learning experience . . . a lot of pressure is on me. Like, oh, I really, really need to know this stuff so I can teach it pretty well. So, I definitely knew my presentation . . . so that was a good learning experience.
In relation to the mock hearing, P5 reflected: “I learned a lot. I was actually the student in the mock hearing and so I learned . . . from their perspective what they might experience, but I also learned from the other side of it too, from the institution side.”
Not all experiential activities were considered impactful. Three participants reflected that the remediation experiential module was confusing. The confusion may reflect on the module but could also be related to the concept that remediation is not a science and requires judgment, experience, and consultation with others. Stated by P8: “It was hard for me to tell [if the student made improvements] because I didn’t have like a clear baseline.” P1 reported: “I mostly ended up just having confusing conversations with the student.”
The ecological gatekeeping map also appeared to be lacking in experiential power. Although the group experience of working together on the module was deemed valuable, three participants could not recall what they learned from the experience. A word count showed participants gave shorter descriptions on the ecological map than on any of the other experiential units. It is possible that a deeper level of preparation in the ecological model would enhance the experiential learning. Understanding the system elements of higher education and how they overlap with gatekeeping is fraught with complexity, even for junior faculty.
Analysis of Reflections Data
The data from the reflections were used to triangulate the interview data. In general, there was a high level of consistency between the reflections (submitted immediately following the modules) and the qualitative interviews (conducted after a time lapse). One interesting finding more evident in the reflections than in the interviews was the description of the emotional reactions to gatekeeping material. At the end of the analysis process, we created word clouds (pictorial displays of word frequencies) of the most common words used by participants. Through this process, we discovered there was a high frequency of a minimum of 12 emotionally laden words such as “scary” and “upsetting” in the data set, with more emotionality expressed in the reflections than in the interviews. Because the reflections were written, it appears that students were more likely to express emotional reactions in reflections than in the qualitative interviews. It is also possible that because the reflections were collected right after the experiential learning activities, emotional reactions were more accessible when the students wrote their reflections than at the time of the interviews.
Discussion and Implications
The CACREP expectation that counselor educators instruct doctoral students in gatekeeping and the awareness that new entrants to the counselor education workplace may experience considerable distress in their roles as gatekeepers inspired the study. Although gatekeeping and remediation may require a relatively small time commitment for new counselor educators, the nature of the work can be difficult and legalistic. The predominant goals of the study were to develop and infuse into the doctoral curriculum an experiential model for gatekeeping instruction and to gain insights into the lived experiences of doctoral students as they engaged in the learning modules.
The DEG Model is presented as one approach to doctoral instruction in gatekeeping. The experiential and developmental foundations for the approach are strongly supported in research, but literature on the application of these theories to the context of teaching gatekeeping to doctoral students was not available. Thus, the DEG Model and the qualitative study of the student learning experiences with the model are exploratory in nature. Nine students reported their perceptions and reactions to the DEG Model. An analysis of the lived experience of the students led to the discovery of four themes: importance of gatekeeping, behind the curtain, understandings vary by developmental level, and uneven responses to experiential learning.
All nine participants were of one mind that gatekeeping, dispositional assessment, and remediation are important. Given that all nine students were from different master’s programs representing institutions located in various regions of the country, this finding suggests that gatekeeping has assumed a position of primacy as an essential function in counseling academic programs and an expected role for counselor educators. Earlier gatekeeping research reported hesitancy in trainees related to gatekeeping because of factors such as program culture, lack of protection for the gatekeepers, and confusion about the standards for gatekeeping (Shen-Miller et al., 2015). The results of this study suggest a possible shift in the perspective of new entrants to the counselor education workplace. In addition, state licensure boards have underscored the importance of gatekeeping the profession. Shen-Miller et al. (2015) also found that trainee ambivalence about the gatekeeping role mirrored faculty ambivalence, suggesting that faculty modeling of appropriate gatekeeping and remediation may be a critical factor in the changing attitudes of doctoral students. An alternative viewpoint is that though the students unanimously supported a belief that gatekeeping is important, their belief system may not translate well to their first actual gatekeeping situation as a counselor educator. The study participants had no direct experience with the often painful situations faculty face when legal action or student grievances are directed against them.
The behind the curtain theme illuminated the lack of transparency in gatekeeping, in that students were surprised by the gatekeeping processes. The finding is puzzling because remediation and gatekeeping literature encourages transparency in identification of dispositions, remediation processes, and reasons students might be dismissed from any given academic program. Perhaps for legal or other reasons counselor education programs are somewhat opaque in their explanations of gatekeeping.
The results provide support for delivering content in gatekeeping through developmental and experiential approaches. Consistent with developmental theory (Piaget, 1977) and findings in doctoral instruction in clinical supervision instruction (Baker et al., 2002; Granello & Hazler, 1998), students began the process with concrete understandings and moved toward more complex interpretations. Also, mirroring other studies in doctoral pedagogy (Dollarhide et al., 2013; Granello & Hazler, 1998), students attributed learning to engagement in experiential activities, rarely referencing lectures or reading assignments except as sources of foundational knowledge.
Aligned with developmental theory (Piaget, 1977), we learned that experiential learning must be carefully cross-walked to parallel to the developmental level of the participants. Two of the six modules (Mentoring Students Through Monitoring Remediation and Gatekeeping Through a Systems Lens: Designing an Ecological Gatekeeping Map) contained experiential elements that in retrospect the authors believe were not well aligned with the developmental levels of the students. Regarding the remediation module, at the time of the study, the doctoral students were working to embrace the new roles of teacher, researcher, and clinical supervisor. Adding the difficult-to-define role of remediation mentor was perhaps experienced as role overload. On the ecological map, the authors hypothesized that the task was too complex, requiring more didactic instruction and experience with systems in organizations.
The finding that two experiential elements were perhaps not targeted at the designated developmental level was less critical than the underscoring of the importance of conducting research on pedagogy in doctoral-level courses. Until conducting the study, we were unaware that the two experiential units were problematic and would have argued that the ecological gatekeeping map was one of the strongest experiential components in the DEG Model.
Implications for Counselor Education
The findings of the study led to insights that inform program development and pedagogy for counselor educators. The values branch of program evaluation (Abma & Widdershoven, 2008) advocates the use of qualitative analysis to develop deeper understandings of how knowledge is constructed.
The finding that doctoral students expressed more emotion in the immediate aftermath of experiential activities reinforces the importance of prompt attention to emotional processing after experiential components. The emotional–motivational theory on learning posits that anxiety negatively impacts concentration and desired outcome as well as reduces interest in engaging in future learning experiences in the content area. This relationship is well documented in research on math anxiety (Passolunghi et al., 2019). Anxiety was expressed in some student reflections, but not unexpectedly, as gatekeeping can be laden with conflict.
The results point to several practical pedagogical issues referred to in program evaluation theory by Stufflebeam (2003) as input factors. One such factor is that experiential pedagogy requires more instructional time than didactic instruction. The authors concluded that the importance of gatekeeping and the overall positive results justified the time investment but recognize the difficulties involved in implementing time-intensive experiential activities. The findings reflect another counselor education input issue, which is the importance of building strong relationships with administrators and the legal department in order to offer students the opportunity to gain perspectives on gatekeeping from stakeholders outside the core counseling faculty. The End of the Road: Gatekeeping and Heartbreaking Adversity module could not be implemented without strong relationships with administrators and legal services.
The unique contributions of this study for counselor educators include an underscoring of the importance of instructing doctoral students in gatekeeping and the power of using experiential strategies. The interview data showed that students initially had a concrete interpretation of gatekeeping, but through participation in the experiential modules, they reported more comprehensive understandings. The importance of matching the learning experience to the developmental level of the student has been previously well established in developmental theory, but through the study we gained the insight that doctoral instruction in gatekeeping should begin at a concrete developmental level. The doctoral students in our study may have been advanced in terms of clinical and research skills, but their initial understanding of gatekeeping was unidimensional.
The study also underscores the importance of helping students reflect and identify their individual belief systems and personal approaches to gatekeeping. Although legal services may recommend that faculty consistently speak in one voice on gatekeeping issues, an essential first step in eventually developing departmental consensus is transparency between individual faculty on their differing perspectives. Beyond the department level, this ongoing conversation is also foundational to growing the profession in our collective understanding of gatekeeping. The study highlights the importance of starting this process at the doctoral student level.
Limitations and Future Research
One limitation of the study is that qualitative research is not intended to be generalized. Therefore, it is unknown if the findings apply to doctoral students enrolled in other counselor education programs. Although there were advantages in utilizing a participant pool with different levels of engagement in the DEG Modules, a limitation associated with this research team decision was that participants who had only experienced early modules may have reflected different perspectives if they had been interviewed after participation in the final modules. Second interviews were not conducted. Another limitation is that the students, though not enrolled in courses from the lead author at the time of the study, may still have been influenced to offer a positive perspective on their learning experiences. Follow-up post-graduation interviews could be a useful mechanism to address this limitation.
A limitation inherent in the design of the DEG Model is that although the design was appropriate for the context of one CES doctoral program, it may not be applicable to the institutional environments of other CES doctoral programs. The context of a high research institution may differ from an institution with a stronger focus on teaching, which could influence student reactions to the DEG Model. A second limitation related to the model itself is that departmental agreement was necessary to infuse gatekeeping material into three courses with different instructors with differing personal values and beliefs on gatekeeping. In addition, agreement to include doctoral students in master’s remediation experiences and admissions interviews was necessary to implement the DEG Model. This level of faculty collaboration may not be possible in all doctoral programs.
More research on counselor education doctoral preparation is needed. The dearth of CES research on pedagogy for instructing doctoral students is apparent in content areas well beyond gatekeeping. Within pedagogy for doctoral student preparation in gatekeeping, research is needed on outcome measures for the attainment of gatekeeping competence. In addition, a greater understanding of the impact of the personal experiences of those doctoral students who were remediated during their master’s preparation on their perspectives as future gatekeepers would be useful to the profession. Also, research on the amount of instructional time needed to effectively teach gatekeeping to a level of minimum competence is needed.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Brenda Freeman, PhD, NCC, LCPC, CPC, is a professor at the University of Nevada, Reno. Tricia Woodliff, PhD, NCC, ACS, CPC, is an assistant professor at the University of Nevada, Reno. Mona Martinez, PhD, CPC, is Downing Clinic Director at the University of Nevada, Reno. Correspondence may be addressed to Brenda Freeman, William Raggio Building Rm. 3007, University of Nevada, Reno/0281, Reno, NV 89557, email@example.com.
Janeé R. Avent Harris, Jasmine L. Garland McKinney, Jessica Fripp
Many African Americans utilize religious coping strategies when responding to life transitions and challenges. Although research related to religious coping practices is represented in the literature, studies related specifically to African Americans are limited. Therefore, the purpose of this qualitative phenomenological study (N = 7) was to investigate the religious coping practices of Christian African Americans. The following six themes emerged: (1) God is a keeper: Getting through the “valley”; (2) positive religious coping; (3) negative religious coping; (4) spiritual growth; (5) “godly counsel” and “sound doctrine”; and (6) “Black people do not go to counseling.” Implications for counselors in providing more culturally relevant services, assessing for religious coping strategies, and collaborating with local faith communities are included. Recommendations for future research are provided.
Keywords: African Americans, religious coping, Christian, qualitative, phenomenological
According to the National Institute of Mental Health (NIMH; 2016), 44.7 million adults live with a mental illness in the United States. However, less than 50% of those adults participate in mental health services. Although the value of mental health treatment is not relegated to a particular group, participation in mental health treatment among the general population remains inconsistent. Notably, African Americans are less likely than other racial and ethnic groups to attend counseling services, but they live with more severe conditions because these matters remain unaddressed (Fripp & Carlson, 2017; National Alliance of Mental Illness [NAMI], 2018). The American Psychiatric Association (APA; 2017) reported that only 1 in 3 African Americans who need mental health treatment receive it, utilizing services at lower rates than non-Hispanic Whites. Similarly, Dalencour et al. (2017) noted that between 2008 and 2012, roughly 30% of African Americans with a mental illness utilized services to treat their condition. Although poverty and exposure to violence are not exclusive to African Americans, these experiences exacerbate the development of mental health conditions (Kawaii-Bogue, Williams, & MacNear, 2017), resulting in post-traumatic stress disorder, major depression, suicide, and attention deficit hyperactivity disorder among this particular population. African American women, in particular, often face the pressure to adhere to the “strong Black woman” image (Matthews, Corrigan, Smith, & Aranda, 2006, p. 258), as they are expected to manage stressors without assistance.
Better mental health can increase overall wellness, build resilience, and provide individuals with the necessary tools and coping skills to combat mental health symptoms. Although these benefits reduce the negative psychological, behavioral, and emotional impact of life stressors, certain factors prevent African Americans from seeking services for symptomology. NAMI (2018) reports that a lack of understanding about the benefits of mental health is a contributing factor that distances African Americans from the services they need. They are often unfamiliar with the warning signs of mental health symptoms and report apprehension about accessing care (Avent Harris & Wong, 2018). For African Americans that do access care, they can receive the wrong diagnosis or be prescribed higher dosages of medication (NAMI, 2018). Additionally, when African Americans believe there is a mental health problem, they take concerns to a primary care provider versus a mental health professional (Hays & Lincoln, 2017). Often, African Americans feel most comfortable seeking support for emotional and mental health concerns from their religious communities (Avent, Cashwell, & Brown-Jeffy, 2015).
Faith and spirituality are reliable resources for African American communities (Hays & Lincoln, 2017; NAMI, 2018; Young, Griffith, & Williams, 2003) and can provide a means to cope when engagement in counseling services is low. Turner, Hastings, and Neighbors (2018) conducted a study with a large number of participants (N = 5,008) focusing on the mental health help-seeking patterns of African American and Black Caribbean adults. These researchers sought to understand the relationship between race, ethnicity, religion, and help-seeking. Their results indicated that older adults with a stronger connection to their religion were more likely to participate in counseling (Turner et al., 2018). In many ways, this finding conflicts with some previous findings that suggest higher religiosity might decrease mental health treatment usage (Avent Harris & Wong, 2018). Researchers must continue to investigate this phenomenon and seek opportunities to harness religious coping as a pathway to mental health and wellness among African Americans.
The Role of Religious Coping in Mental Health
Although researchers are intrigued by religion’s role in mental health outcomes, religious coping remains a complicated construct to unpack. Religion is often a source of support and provides a sense of meaning when experiencing difficult life stressors (Park, 2005). According to Jackson and Bergeman (2011), multiple benefits for religiosity include resilience, broader support system, sense of meaning and hope, and perceived control over circumstances. Religious coping is often accessible and includes but is not limited to prayer, meditation, and worship (Pargament, Smith, Koenig, & Perez, 1998).
Pargament, Feuille, and Burdzy (2011) recognize Pargament et al.’s (1998) Brief Religious Coping (Brief RCOPE) scale as the most common assessment of religious coping. In this quantitative assessment, individuals can identify the particular religious coping strategies they use (e.g., looked for a stronger connection with God). Pargament et al. (1998) found that religious coping can be classified as negative or positive. Usually those who employ adaptive coping strategies create opportunities to incorporate belief in God in a healthy way, coalescing religious strategies with coping tools received in mental health treatment. However, it also is possible for individuals to engage in maladaptive forms of religious coping. This is characterized by depending solely on God for action and often blaming God when adverse circumstances persist (Avent, 2016; Pargament et al., 1998). Maladaptive religious coping is linked to negative health outcomes (Pargament et al., 2011). Further, there are psychological implications of negative religious coping. When individuals depend solely on spirituality without therapeutically confronting traumas and emotional symptoms, they miss opportunities to uncover and appropriately heal from past and present hurts (Avent, 2016). Although African Americans are known to use faith and spirituality to address emotional, physical, and psychological concerns, the research remains limited on how these strategies are enacted.
Although there is extensive research with the Brief RCOPE, Pargament et al. (2011) recommend further investigation into the instrument’s application with diverse populations. The brief nature of the assessment allows counselors to obtain information in a short amount of time; however, it might limit the amount of data collected and other styles of religious coping can remain unaccounted for. Thus, it is important for counselors and counseling researchers to seek more information about the religious coping practices of individuals, such as African Americans, who are historically underrepresented in mental health research and central to the conversation on mental health and spirituality.
African Americans’ Use of Religious Coping
The Pew Research Center (2018) reported that African Americans are more likely to identify as Christian than other Americans in the United States. Eighty-three percent of African Americans believe in God with absolute certainty (Pew Research Center, 2018) and 75% consider religion to be important in their lives. Seventy-five percent of African Americans report that they pray daily (Pew Research Center, 2018). Given the salience of religion in the lives of African Americans, it is imperative for counselors to consider how these beliefs inform coping practices. Chatters, Taylor, Jackson, and Lincoln (2008) reported that African American and Black Caribbean women were more likely to use religious coping than men, and those who are married utilized religious coping more than those who are unmarried.
Although African Americans have increased their proximity to mental health resources, preferences toward religiosity over formal help-seeking remain (Dempsey, Butler, & Gaither, 2016; Hardy, 2012). Hankerson, Watson, Lukachko, Fullilove, and Weissman (2013) conducted a series of focus groups with African American pastors of a predominantly Black megachurch in New York to learn more about individuals’ experiences with depression and the role and responsibilities of churches to respond to this diagnosis. Through consensual qualitative research, the scholars found that pastors prayed with members and provided them scripture-based guidance. The pastors also mentioned referring parishioners to more formal counseling services depending on the severity of the issue. However, the church remains an integral part of African Americans’ coping support systems (Campbell & Littleton, 2018). Similarly, Avent et al. (2015) found that Christian African Americans seek out religious supports for a diverse range of life circumstances, often going to their pastor for guidance rather than a professional counselor. These strong ties to faith communities and reliance on religious coping support warrant additional attention from counseling researchers and practitioners.
The integration of an individual’s religious and spiritual background is not only culturally responsive, but it is considered ethically responsible in treatment (American Counseling Association, 2014; National Board for Certified Counselors, 2016). However, given the dearth of literature that exists that focuses explicitly on Christian African American experiences with religious coping, counselors may feel ill-prepared to have these critical conversations and unequipped to integrate these interventions and techniques in the therapeutic relationship. Therefore, the purpose of this study was to investigate the religious coping practices of Christian African Americans. The research question that guided the study was, “What are the experiences of Christian African Americans who use religious coping practices?”
The purpose of phenomenology is to unearth the essence of individuals’ experiences with a particular phenomenon (Moustakas, 1994). This research approach assumes that multiple realities can co-exist simultaneously and juxtaposes more positivist, quantitative perspectives that suggest a certainty in knowledge (Hays & Singh, 2012; Hays & Wood, 2011), and participants can share their personal experiences with the phenomenon under investigation (Hays & Wood, 2011). In this case, this methodological approach seemed to be most appropriate to investigate the experience of African Americans in using religious coping to respond to life stressors. More specifically, in regards to counseling research, phenomenology is often used to explore issues related to culture and diversity (Flynn, Korcuska, Brady, & Hays, 2019).
The research team consisted of the first and second authors. Both team members identify as Christian African American women with personal experience and professional interest in the study’s phenomena. The first author is an assistant professor with a background in teaching and conducting qualitative research. The second author is a master’s-level counseling student with previous research experience.
The research team remained intentional throughout the methodological procedures to minimize the influence of their own biases and expectations. For example, the team met before data collection to engage in bracketing. Through bracketing, the research team discussed their own experiences and how they may impact their relationship to the study and understanding of the data. The bracketing continued through the data analysis process when the team members identified any reactions to the data and agreed to hold each other accountable in minimizing the impact of their own biases on the findings (Hays & Singh, 2012).
One of the critical elements of the phenomenology approach is the intentionality in choosing participants; eligible participants are considered those who have an in-depth and intimate knowledge of the phenomena (Hays & Singh, 2012). Eligible participants were adults who identified as African American and Christian, recruited through purposive and snowball sampling methods via social media postings and email, and invited to tell others who may be interested (Hays & Singh, 2012).
In total, seven participants responded and completed the interview. This number of participants is sufficient for phenomenology methodology (Creswell, 2013). All the participants identified as heterosexual women. The recruitment was open to men as well. Two men indicated interest in participating but did not follow through with completing the interview. Of the seven participants, five indicated their relationship status as married and two described themselves as single. The participants’ ages ranged from 26–58 years old, and the mean annual income of participants was $69,071. This study revealed a mix of denominations: Two participants identified as non-denominational, and one participant each identified as Methodist, Christian, Pentecostal, Protestant, and Presbyterian, respectively. Three participants graduated with their master’s degree, one graduated with a doctorate, two graduated with bachelor’s degrees, and one indicated that she was currently attending college. Three participants indicated they had participated in counseling services, three indicated they had not, and one indicated participation in pastoral counseling.
It is important to situate the current study’s participants’ demographics within the context of the larger society. Generally, African American women earn less than African American men and White men and women (Hegewisch & Hartmann, 2019). The median income of the current participants is higher than the median income of African American households in the United States (i.e., $40,258; Fontenot, Semega, & Kollar, 2018). According to the U.S. Census Bureau (2017), 24% of African American women have at least a bachelor’s degree. In the current study, all of the participants were in college or had obtained at least a bachelor’s degree. The demographics of the current study are promising and reflect within-group differences among African Americans in regards to education and income.
Participants completed a demographic questionnaire and a semi-structured interview. The first author created the interview protocol questions based on what is known in existing literature and areas that warrant further exploration (Hays & Singh, 2012). For instance, there is existing research on religious coping practices; however, the questions in this interview protocol seek to understand Christian African Americans’ perspectives in particular. The qualitative nature of this study created an opportunity for participants to give their feedback on Pargament et al.’s (1998) classifications of negative and positive religious coping. The semi-structured format of the interview allowed the researchers the flexibility to follow up on participants’ responses and explore topics that emerged during the conversation (Hays & Singh, 2012). The interviews ranged from 26 to 48 minutes, with a mean of 36 minutes.
The interview protocol included the following questions: (1) If you have participated in counseling before, please tell me why you chose to go to counseling and about the process; (2) In what ways, if any, have you been encouraged to seek out professional counseling? In what ways, if any, do you feel you have been discouraged from seeking out professional counseling? (3) How would you define religious coping? (4) What are some ways you use your religious practices to cope with life circumstances? (5) In what ways do you think religious coping is beneficial? What are some limitations? (6) Often, people who engage in religious coping are less likely to seek professional counseling services. Why do you think this may be? (7) Tell me about a time you encountered a life challenge and used your religion to cope. What did this look like? How was it helpful? How was it not helpful? (8) Researchers have identified “positive” religious coping strategies and “negative” religious coping strategies. What are your reactions to these? (9) Are there any that you would classify differently? Are there any that you would take away? and (10) Can you think of times when you have used positive religious coping? What about negative religious coping? The interview concluded with asking the participants if they would like to share anything they were not asked and to reflect on their experience in the interview process. Each participant completed the interview individually.
We followed Moustakas’ (1994) modification of the van Kaam method to phenomenological data analysis. We met to discuss bracketing and process our reactions and insights before the data analysis. Then, we analyzed two interviews together and identified themes. These meetings provided the second author with an opportunity to learn the process and feel more comfortable coding data independently. Next, we proceeded to review the transcripts individually, reconvening and discussing emerging themes. Themes emerged from a series of steps that included grouping participants’ words, reducing and eliminating raw data that is not related to the phenomena or might be repetitive, and clustering related statements into overarching themes. We refined the emerging themes again by checking them against the participant interviews a second time. The first author created textural and structural descriptions and shared them with the second author for discussion (Moustakas, 1994).
It is essential that researchers in qualitative studies ensure trustworthiness to maximize rigor (Hays & Singh, 2012). There are several strategies that researchers utilize to increase trustworthiness, and we infused several of these tools in our current study. The procedures in the current study reflect strategies commonly enlisted in counseling research (see Flynn et al., 2019), including our engagement in bracketing throughout the research process.
Additionally, participants received the themes and were invited to provide feedback as a part of the member checking process (Hays & Singh, 2012). Participants who responded (n = 2) agreed with the findings. We included “thick descriptions” (i.e., participant direct quotes) of the data in this article to provide context and supporting evidence for the identified themes. We also maintained an audit trail throughout the research process. Information from the audit trail, documenting the procedures and approaches from this current study, can help readers understand how the researchers arrived at the findings (Flynn et al., 2019; Hays & Singh, 2012).
Auditor findings. The external auditor was a critical part of the trustworthiness process for the current study (Hays & Singh, 2012). Our auditor identifies as a White woman. She is a graduate student who has some experience working on qualitative research studies. The auditor reviewed the participant transcripts, identified themes, and then provided feedback regarding the research team’s findings. The auditor’s findings were consistent with the research team’s themes. The auditor did note the participants’ acknowledgment for the need for professional counselors. The research team had not highlighted this perspective. Thus, we incorporated this into the discussion of the findings.
We identified the following themes: (1) God is a keeper: Getting through the “valley”; (2) positive religious coping; (3) negative religious coping; (4) spiritual growth; (5) “godly counsel” and “sound doctrine”; and (6) “Black people do not go to counseling.” The following section will expound on these findings and provide support for the themes.
God Is a Keeper: Getting Through the “Valley”
The participants recalled challenging times and transitions such as grief and loss, divorce, physical sickness, and financial difficulties. Although these defining moments are universal in the human experience, the participants interpreted these challenges through the lens of the attributes of God and their religious beliefs. The name of this theme came directly from one of the participant’s responses as she spoke to the vital role God played in sustaining her through the difficult times. This sentiment resonated with five of the seven participants, who identified God as the reason why they were able to endure struggles. God was referred to as a “keeper” either explicitly or implicitly in many of the interviews. Charisma stated, “I do believe that salvation has kept me through a lot of difficult times.” This participant identified the loss of her sibling as her most challenging circumstance, and she recalled vividly how her relationship with Christ kept her through that challenge, even as a young person. Many participants identified their challenges as the catalyst for identifying who God is in their life and connecting with this attribute. Tee defined religious coping as “a heavy or absolute reliance on God to get you through whatever . . . the trauma is or the struggle is, or in religious terms, your valley.”
Further, in many ways the participants closely aligned their church communities with God as “keeping” factors. For example, Amy recalled a “pretty dark time” in her life when she was going through a divorce. She and her husband were very involved in church and were not expecting to separate. She attributes the connection to her church, pastoral counseling, and friendships with sustaining her during that time. Amy, like many of the participants, found solace and community in her church family. These relationships were crucial sources of coping.
Positive Religious Coping
Religious coping strategies came up numerous times throughout the interviews because this was a focus of the study. Although the participants did not always talk about positive religious coping in the exact terminology (e.g., sought God’s love and care) presented by Pargament et al. (2011) and Pargament et al. (1998), all of the participants referenced times in their lives when they enacted these strategies. Some of the examples provided by the participants included following God’s direction, use of scripture and prayer to focus, attending worship services, and viewing God as a faith companion. For instance, Donna stated that she prays daily, does morning devotionals, and participates in Bible studies when she is able. She said that these practices are essential to respond to the daily struggles she may encounter. It is important to note that although church was an important element for coping for most of the participants, Kira expressed a different sentiment. Kira expressed discontent with the idea of church, but the concept of religious coping still resonated strongly with her. She spoke about using religion to help her make sense of her circumstances. For her, scriptures provided a source of meaning-making. She also expressed the fact that her understanding of religious coping evolved and deepened as she became older and the scriptures seemed more relevant. When asked, participants tended to agree on the positive religious coping styles presented by Pargament et al. (2011) in the Brief RCOPE scale and acknowledged the fine line between adaptive and maladaptive religious responses.
Negative Religious Coping
Although most participants more readily offered examples of positive religious coping, negative religious coping came up in each interview more implicitly. Some of the sentiments expressed in the interviews included jealousy, frustration, “the devil,” questioning God, isolation, lack of trust, “why me?,” “God is enough,” and a sense that moments of doubt or struggle can indicate a betrayal of God.
Toni recalled a time in her career when she felt that she had enacted negative religious coping. She said that she made statements such as “the devil must want me to be here right now.” Similarly, Kira spoke about hearing others say, “The devil this, the devil that.” After hearing the negative religious coping strategies from Pargament et al. (2011), Kira stated that although she had not felt completely abandoned by her church, she felt misunderstood many times. Tee also recalled the ways in which negative religious coping intersected with mental health in her upbringing. She remembered hearing messages such as “you just need to pray about it” and “suck it up because you’re strong.” These negative messages seemed to be perpetuated both in church and within the immediate family, as participants were encouraged to “not share family business.”
Spiritual growth and development was an important part of conceptualizing and responding to life stressors. Participants often reflected on their faith development and attributed some of their challenges with triggering their growth. Jonica explained her journey from a young person “going through the motions” to an adult with a “relationship with God for myself.” Through this process she learned from preachers and her family to seek consultation in the scriptures. The participants spoke about the impact that their spiritual maturity has had on their coping strategies and responses to life circumstances. Many of the participants stated that they were much more spiritually mature now and, therefore, would have a more faith-based response to challenges as they arise. For instance, Donna recalled her experience with cancer and the ways the process impacted her spiritual development. She stated that her response would be different now because of her spiritual maturity. Previously she considered the cancer diagnosis as a death sentence, felt unloved by God, and was angry. Now, she said she would “smile about it and keep it going.”
For many, the church also tended to be an integral part of personal faith and spiritual development. The worship experience, in particular, was seen as a therapeutic release. Although many of the connections to the church were positive, there were some points of tension. It is important to note how different individuals’ experiences can vary. For some, the church was a path to a stronger relationship with others. For some participants, like Toni, negative experiences with the church were traumatic and created distance between the individual and their local fellowship. She recalled that “the church I grew up in was very fire and brimstone.” Whether the experiences were positive or negative, the church served as a conduit in the participant’s spiritual journey and development.
“Godly Counsel” and “Sound Doctrine”
Participants emphasized the value of the Bible and the role it played in providing guidance and direction throughout their lives, particularly during challenging situations. Often, participants juxtaposed this idea of “godly counsel” with secular counseling services. In these cases, participants emphasized the importance of advice that did not contradict the “word of God.” Charisma stated, “therapy is godly and providing you with godly wisdom” and can be a supplement to pastoral instruction and prayer. Similarly, Amy stated that she could have benefited from professional counseling but instead relied solely on pastoral counseling. In this counseling, her pastors prayed with her and gave her “godly wisdom [and] godly advice.” Participants specifically highlighted the importance of the idea of “sound doctrine” as opposed to false teaching to provide direction and comfort. For participants, “sound doctrine” meant that scriptures were properly interpreted and applied.
“Black People Do Not Go to Counseling”
All of the participants highlighted the stigma that exists among many African Americans regarding mental health help-seeking and referred to the notion that “Black people do not go to counseling.” Participants noted that in many African American communities, and especially within traditional Black Church communities, mental health is a taboo subject. The participants identified social media, family, and friends as influences on their attitudes and perspectives toward counseling. Jonica, a long-time educator, recalled some of her experiences with students and families. She noted that Black and Brown communities often have stigma about mental health treatment. A number of her students’ families experienced trauma but were discouraged from counseling because they considered it “for people who are crazy.” Participants noted the lack of African American representation amongst counselors as a potential deterrent. Amy said, “I mean a Black person going to a White person to get help? No.” The participants all agreed that the stigma about mental health treatment needed to end and that more needed to be done to increase mental health help-seeking in their communities.
Statistics highlight the disproportionate use of mental health services by African Americans (APA, 2017). Scholars are challenged to gain a more in-depth understanding of the narratives and experiences behind these figures. Thus, the researchers in this qualitative phenomenological study sought to understand how African Americans utilized religious coping practices in response to challenging situations. Seven women participated in the interviews. This discussion contextualizes the current findings within the current literature landscape and highlights the ways this research offers new understandings.
Overwhelmingly, the majority of African Americans believe that God exists (Pew Research Center, 2018). The findings of this current study support this understanding and also illuminate the ways Christian African American women, in particular, consider God to be at work in their lives. Thus, for Christian African Americans, it is important to not only acknowledge God’s existence, but that God is active in the fabric of their everyday lives. Our participants attributed much of their resilience and ability to cope with God sustaining them through various life circumstances. Although participants did not state that God was their only source of sustainment, they did seem to suggest that it was the most vital. Although the counseling research about African Americans’ perspectives of God is more limited, this finding is consistent with research in other professions. For instance, Woodward and Sowell (2001) conducted a qualitative investigation of women diagnosed with HIV/AIDS. The participants in that study emphasized that “God is in control” as a means of coping and alluding to the involvement of God in their personal lives (p. 240). Similarly, the participants in our study found solace in trusting the sovereignty of God.
Participants in our study spoke about positive and negative religious coping strategies. It is important to note that all the participants in our sample were women, which could explain the centrality of religious coping, as Chatters et al. (2008) found that African American women were more likely to engage in religious coping practices than African American men. The participants used religious coping as a support but also as a way to make meaning, particularly in stressful situations. Although much of the literature on the intersections of faith and mental health focuses on the influence on help-seeking, the responses from these participants also provide insight into meaning-making, which is important for counselors to understand as they work with this population.
Although the focus of this current study was on religious coping, our participants spoke a great deal about faith development. Many of the insights shared aligned with popular faith development models, such as Fowler’s (1981) Stages of Faith. Thus, one can assume that a particular stage of faith may inform the type of religious coping strategy utilized. Moreover, the participants seemed to suggest that higher-order stages of faith (i.e., those stages that involve more self-reflection, awareness, openness, and the ability to acknowledge the existence of multiple truths) aligned with more positive religious coping strategies. Although an in-depth description and analysis of Fowler’s Stages of Faith is outside the scope of our study, it is important to discuss to offer some additional context for this particular theme and as a way for counselors to deepen their client conceptualizations and inform their therapeutic interventions (Parker, 2011).
The emphasis on the Bible as a coping mechanism is consistent with data from the Pew Research Center that reports that 54% of African American adults read scripture at least once per week and 51% support a literal interpretation of scripture. Thus, African Americans may be inclined to endorse scripture texts that identify suffering as a means of entry into heaven. For instance, 1 Peter 5:10 (New International Version) states: “And the God of all grace, after you have suffered for a little while, will himself restore you and make you strong, firm, and steadfast.” The ideas of suffering are extraordinarily nuanced for African Americans, as religion became a way to cope with and understand oppression. Some Black Church theologies consider suffering as a means to the desired reward in heaven (Avent & Cashwell, 2015). These theological underpinnings and understandings of scripture have an essential influence on African Americans’ preference for religious coping and under-utilization of counseling services (Avent & Cashwell, 2015).
Overall, the findings that emerged support longstanding notions that mental health stigma is prevalent in African American communities and that religion and spirituality are critical components of coping responses and understanding help-seeking patterns (Avent Harris & Wong, 2018). It is noteworthy that participants in our study were generally supportive of participating in counseling; three of the participants had participated in secular counseling. Therefore, the current findings suggest that even when negative attitudes are absent, it still might not result in help-seeking. Thus, it is time to move beyond seeking to solely understand attitudes toward help-seeking and learn more about actual coping behaviors.
One participant noted that the lack of African American counselors might serve as a deterrent for many African Americans because they may not feel comfortable opening up to someone who is Caucasian. Currently, African Americans comprise 18% of master’s students enrolled in counseling graduate programs (Council for Accreditation of Counseling and Related Education Programs, 2017). Studies such as Kim and Kang (2018) found that clients who had counselors with the same racial/ethnic identity attended more counseling sessions. Thus, counselor education programs should consider intentional recruitment efforts to increase the number of African Americans enrolled in graduate counseling programs in order to diversify the workforce. These efforts could lead to more African Americans engaging in professional counseling.
Implications for Counselors
There are many important implications for counselors from the findings of our study. First, although African Americans are confronted with many stressors stemming from both systemic oppression and universal human experiences, our participants demonstrated resilience. Counselors should be intentional in identifying strengths and highlighting ways African American communities, often led by Black churches, have persisted (Avent et al., 2015; Lincoln & Mamiya, 1990). Although counselors should ensure that they are aware of cultural barriers that contribute to a lack of participation in counseling resources, they also should be intentional about highlighting the important ways religion, spirituality, and churches are a trusted resource and source of advocacy (Avent et al., 2015; Avent Harris & Wong, 2018).
Findings from our study support the extant literature reporting that African Americans frequently adhere to cultural beliefs that suggest “Black people do not go to counseling” and are more comfortable utilizing their faith (Avent Harris & Wong, 2018; Schnittker, Freese, & Powell, 2000). This could stem from a lack of trust for mental health professionals to provide an environment that is both non-judgmental and confidential. Counselors should intentionally work to earn trust and build rapport among African Americans. One potential means to increase African American participation in counseling would be to host group therapy sessions in churches led by professional counselors. Hankerson et al. (2013) found that pastors were open to the idea of hosting group sessions and likened them to peer support groups that might already exist. For many African Americans like the participants in our study, therapeutic groups can be attractive when they are held within the context of a religious setting and can help to reduce mental health stigma.
Although it is important to emphasize the importance of help-seeking from secular counselors, our study acknowledges value in the church as a resource and an integral part of the support networks of many African Americans. Hankerson et al. (2013) encouraged engaging Black churches as stakeholders in advancing mental health awareness and treatment. Results from our study confirm that pastors often provide both spiritual and personal counseling to members of their churches. The church has proven to be a consistent place of solace for many African Americans whether members are participating in premarital, financial, or other counseling (Avent Harris & Wong, 2018). Thus, counselors can create professional relationships with church leadership to connect to church members (Robinson, Jones-Eversley, Moore, Ravenell, & Adedoyin, 2018).
Dempsey et al. (2016) provided an overview of examples of successful collaborations with community stakeholders and Black churches. Most of these connections focus on physical health initiatives. Thus, it is incumbent upon counselors to harness support networks; the authors challenge counseling professionals to consider these collaborations as a template for mental health-focused programming. Dempsey et al. suggested the following steps can make these efforts successful: awareness, assessment, seeking approval, church health fairs, mental health training, joining the community, conducting research, and inviting wisdom. Furthermore, many historically Black fraternities and sororities have created initiatives strategically targeted to increase education and awareness around Black men’s mental health. As these organizations often have significant ties to local churches, they serve as a great partner for counselors and professional organizations.
It is vital that mental health professionals approach collaborations as mutually beneficial and growth-fostering (Jordan, 2010). That is, counselors need to be careful not to consider themselves experts, but to invite wisdom from church leaders (Dempsey et al., 2016). Participants in our study repeatedly talked about their pastors and the counseling they received from their church leaders. Although counselors are clinically trained through graduate courses and continuing education, they might consider seeking training from pastors on building rapport and relationships with African Americans. It is important to note that although licensed counselors have some commonalities in their training (e.g., CACREP standards) and must have graduate degrees, training and educational experiences among pastors vary greatly. Therefore, when forming collaborations, counselors should be aware that pastors can have varying levels of knowledge and experience related to mental health and counseling skills.
Assessment of Religious Coping
The Association for Spiritual, Ethical and Religious Values in Counseling competencies challenge counselors to consider religion and spirituality in their assessment procedures (Cashwell & Watts, 2010). Although religion and spirituality can be assessed informally or qualitatively through intake forms, the Brief RCOPE (Pargament et al., 2011; Pargament et al., 1998) provides counselors with a structured, quantitative scale. Our participants were more hesitant to volunteer information about harmful religious coping practices. However, this lack of admission did not mean they were not utilizing maladaptive practices. Researchers have noted the consequences of maladaptive religious coping (Pargament et al., 2011) on health. These considerations are especially important for African Americans as they are disproportionately represented in many physical illnesses (Singh et al., 2017). In using the Brief RCOPE scale, counselors can intercept religion as a barrier to help-seeking behaviors and in turn might promote positive religious coping strategies and significantly decrease delays in receiving mental health treatment as a result of negative religious coping (Chatters et al., 2008). Furthermore, the Brief RCOPE can serve as an important conversation starter for counselors to engage their clients about their religious coping patterns.
Recommendations for Future Research
There are many opportunities to increase our understanding of this phenomenon through future empirical investigations. Inquiries can be both qualitative and quantitative. Future researchers could replicate our qualitative study with an added emphasis on recruiting men to participate. African American men seek help less often than African American women (Sue & Sue, 2016). Therefore, future research studies should focus on the narratives of African American men in order to inform culturally relevant practices to recruit and retain this population for counseling services. Flynn et al. (2019) recommended that counseling researchers also consider diverse data types in addition to traditional interviews and focus groups. For example, researchers could ask participants to include songs that help articulate religious coping patterns; then, song lyrics could be analyzed for themes as well.
It is important to consider our findings within the limitations of the study. First, all of the participants were women. Thus, it is unclear how gender could have impacted our results and how our findings might have differed if gender representation was more diverse. Although the data reached saturation, there may have been an opportunity to learn more about this phenomenon with an increased number of participants. An additional limitation is minimal participation (n = 2) in member checking. Increased participation in this process might have challenged the research team’s perspectives and could have increased the overall trustworthiness of the findings.
The participants in our qualitative study identified six themes that highlight the essence of Christian African Americans’ experiences with using religious coping to respond to challenging life circumstances. These themes confirm existing literature by reiterating the importance of religious coping and the stigma that often exists in African American communities regarding seeking formal counseling services for their emotional and mental health. Counselors have a unique opportunity to use the religious coping practices of African Americans to strengthen the cultural relevance of treatment modalities and guide collaborations with community stakeholders and faith leaders.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Janeé R. Avent Harris, NCC, is an assistant professor at East Carolina University. Jasmine L. Garland McKinney is a graduate research assistant at East Carolina University. Jessica Fripp, NCC, is an assistant professor at Austin Peay State University. Correspondence can be addressed to Janeé Harris, 225A Ragsdale Hall, Mail Stop 121, Greenville, NC 27858, firstname.lastname@example.org.
Gulsah Kemer, Jeffry Moe, Kaprea F. Johnson, Emily Goodman-Scott, Zahide Sunal, Chi Li
We conducted a confirmatory factor analysis (CFA) to obtain validity support for the Consultation Skills Scale (CSS) in a sample of 369 counseling professionals and interns. Upon obtaining a poor model fit from an initial CFA, we utilized modification indices and removed nine items from the CSS. As a result, we achieved a better model fit for the shorter 8-item instrument (CSS-S). To further examine validity of the CSS-S, we also explored the relationships between counselors’ consultation skills and two related professional activities, ability to foster supervisory working alliance and ability to engage in interprofessional collaboration. We discuss the results along with the implications for further practice and research as well as limitations to the current study.
Keywords: consultation skills, confirmatory factor analysis, counseling professionals, supervisory working alliance, interprofessional collaboration
As an important component of counselors’ scope of practice (Kurpius & Fuqua, 1993; Scott, Royal, & Kissinger, 2015), consultation is included in the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) standards, referenced in the American Counseling Association (ACA) Code of Ethics (2014), and supported as a best practice for helping counselors resolve ethical dilemmas (Sangganjanavanich & Lenz, 2012). Literature on consultation encompasses diverse professional perspectives, models, and theoretical frameworks (Brown, Pryzwansky, & Schulte, 2011; Goodman-Scott, 2015; Moe, Perera-Diltz, & Sepulveda, 2010). In an attempt to define consultation for professional counselors, Scott et al. (2015) proposed that consultation is a professional helping relationship in which a consultant seeks to foster growth and change to benefit the consultee, the consultee’s clients, and the organizational context in which the consultee provides services. Both mental health and school counselors utilize consultation to enhance practice and support recognized standards of care. As a distinct mode of intervention, consultation is recognized as a key component of the Multicultural and Social Justice Counseling Competencies (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015), in which counselors are strongly encouraged to act outside of the counselor–client dyad to advocate for the competent provision of services to marginalized groups.
Consultation as a Distinct Area of Practice
In the consultation literature, scholars tend to conflate consultation with other related practices, such as supervision and interprofessional collaboration. The practice of consultation does overlap in some areas with both supervision and interprofessional collaboration, while differing in how the duty of care toward identified clients and students is shared between professional stakeholders. In supervision, the relationship rests on a de facto hierarchy in which supervisors take on ultimate responsibility for ensuring the standard of care is being met and utilize consultation as one of their supervisory roles (Bernard & Goodyear, 2018). In interprofessional collaboration, the duty of care is co-equal across the specific roles and functions of the collaborating care providers. In consultation, on the other hand, the duty of care rests with the primary provider, though consultants are obligated to act ethically within the consultation relationship. These general comparisons between consultation, supervision, and collaboration, however, are not rigid and the skill sets, responsibilities, and best practice guidelines governing a specific relationship between two professionals may share elements of each depending on context. Developing competency in each area appears to share a common theme, though counselors and other helping professionals should be intentional about practicing through the lens of a coherent, guiding framework when engaging in supervision, consultation, or interprofessional collaboration with other professionals and on behalf of the clients and students being served. Although recent scholarship on supervision and collaboration can be found supporting the efficacy of each intervention, recent scholarship on consultation in the professional counseling literature is largely conceptual and continues to lack robust empirical grounding. In our study, we addressed these gaps by obtaining further validation of a consultation skills instrument, the Consultation Skills Scale (CSS; Moe, Perera-Diltz, & Sparkman-Key, 2018).
The Need for Counseling-Specific Consultation Research
Given the commonality of peer consultation and collaboration across the various health care and allied fields (Newman & Ingraham, 2017), it is imperative to consider the research base on the apparent efficacy of consultation as an adjunctive practice. Research on consultation is similar to research on clinical supervision in counseling, with outcome-based research focusing on the effect consultation has on the consultee as opposed to clients or organizational contexts. The main evidence-based outcome of consultation appears to be improvement in treatment integrity or fidelity, with this effect being documented with consultees working with both youth (Brennan, Bradley, Allen, & Perry, 2008) and adults (Collier-Meek & Sanetti, 2014). The improvement of practitioners’ treatment fidelity attributable to the effect of consultation has been documented in manualized, experimental research (Ruble et al., 2018), and with single-subject design research (Smith, Eichler, Norman, & Smith, 2015). As supervision is only mandated for counselors during distinct periods early in their training, Ruble et al. (2018) suggested that consultation as a mode of intervention is ideal for diffusing innovation and evidence-based practice throughout counselors’ career development. For example, promising results have been generated in the critical area of child and adolescent behavioral and mental health consultation, in which consultants are viewed as enhancing the standard of care being provided by another primary therapist (Vuyk, Sprague-Jones, & Reed, 2016). The ability to diffuse affirmation of lesbian, gay, bisexual, transgender, and other gender- and sexuality-diverse people as the standard of care in mental health work also appears to be supported through consultation practice (Moe et al., 2018).
In a comprehensive meta-synthesis of qualitative studies sharing a focus on consultation processes, five cross-cutting themes were identified related to best practice in consultation implementation (Newman et al., 2017). The five themes were: (a) taking system-level factors into consideration;
(b) providing consultation in a coherent and consistent manner; (c) creating space for consultee voice, social-emotional support, and learning; (d) striving for ecologically valid and culturally competent consultation practice; and (e) obtaining sufficient training to apply relational process skills before engaging in consultation (Newman et al., 2017). These themes are echoed within both classic and recent scholarship on consultation and underscore the need for training in consultation as a distinct intervention. What training is needed specifically, and how to assess training in consultation, is an overlooked area in the professional counseling and counselor education literature base. As an under-researched area of scholarship (Guiney, Harris, Zusho, & Cancelli, 2014; Sangganjanavanich & Lenz, 2012), the dearth of counseling-specific consultation research may exist because of the lack of a valid measure specifically designed to assess counselors’ consultation skills and proficiencies. Guiney et al. (2014) developed the Consultation Self-Efficacy Scale (CSES) to assess school psychologists’ relative self-efficacy for implementing consultation. Presenting a complex framework, the CSES defined consultation self-efficacy as comprised of six interconnected domains that overlap substantially with common professional helping skills (e.g., communication ability, multicultural sensitivity). This conceptual foundation for the CSES is more aligned with the profession of school psychology as opposed to counseling, limiting our ability to use it for assessing counselors’ general skills and proficiency in consultation.
Moe et al. (2018) developed the theory-based CSS, focusing on counselors’ perceived knowledge of consultation models and frameworks and related consultation skills as a distinct practice modality akin to group counseling, clinical supervision, and crisis response (Brown et al., 2011). Rather than practicing consultation as an adjunct or supplement to their preferred mode of counseling, the CSS incorporated awareness of models, interventions, and dispositions identified in the literature base as distinguishing consultation from other modes of professional helping. The items for the CSS were created using a rational-empirical approach, with the aim of developing a construct that would assess respondents’ awareness of consultation theory, process, and skills, and relative adherence to the idea that consultation is a distinct area of practice as opposed to an ad hoc one. In a study specifically examining counseling professionals’ lesbian, gay, and bisexual counseling competence in relation to their consultation skills, Moe et al. established the initial construct validity for the CSS through an exploratory factor analysis (EFA). However, Moe et al. stated that the targeted sample and sample size in the study were limited, requiring further collection of validity evidence for the CSS.
Purpose of the Study
In our study, we aimed at further examining the validity and reliability properties of the CSS to advance our knowledge base regarding consultation skills and proficiency among counselors. Thus, our research questions were: (1) Is the unidimensional structure of the CSS confirmed with a cross-validation sample? (2) Does the CSS demonstrate different types of validity (i.e., convergent, divergent, concurrent, incremental)? and (3) Is the derived factor internally consistent and stable? We explored validity evidence for the CSS by testing the factorial structure through a confirmatory factor analysis (CFA). We also further tested validity evidence for the instrument by assessing the relationships between participants’ scores on the CSS and two related constructs: supervisory working alliance and interprofessional collaboration. Finally, we explored the reliability properties of the CSS.
Demographics for participant (N = 369) cultural background, gender identity, age, years of experience, counseling specialty, training in consultation, and highest degree earned are reported in Table 1. Only participants who completed all measures plus the demographic information were included in the present study.
Self-Reported Participant Demographics (N = 369)
Gender Identity Number % Total
Male 101 27.4
Female 245 66.4
Choose Not to Respond 23 6.2
White, Non-Hispanic 298 81.0
Black/African American 9 2.4
Latinx/Hispanic 15 4.1
Asian/Asian American 10 2.7
Native American 4 1.1
Multiple Heritage 15 4.1
Other Background 5 1.4
Choose Not to Respond 12 3.2
Highest Earned Degree
Bachelor’s 80 22.0
Master’s 265 72.0
EdS 11 2.5
Doctorate 13 3.5
School Counseling 41 11.1
Clinical Mental Health Counseling 219 59.3
Counselor Education 25 6.8
College Counseling 12 3.3
Addictions Counseling 7 2.0
Rehabilitation Counseling 47 12.7
Other 18 4.8
Training in Consultationa
No Training 89 24.1
Required Course 181 49.0
Elective Course 54 14.7
CEUs 135 36.5
Supervised Practice 115 31.2
Range 24 to 79
Range 6 months to 48 years
aTraining in consultation percentage not cumulative; participants could report more than one type of training.
Data Collection Procedure
We recruited participants via direct email and posting announcements to professional counselor-focused listservs such as CESNET and COUNSGRADS. We accessed emails through the purchase of a member email list from the American Mental Health Counselors Association, whose membership is comprised of self-identified mental health counselors, and the publicly available contact information for practicing school counselors in Virginia, as well as members of national and state school counselor professional associations. Because of the use of the web-based survey method for recruiting participants via the internet, we could not calculate a rate of response. Although we knew the total number of available emails in advance, the number of non-working emails and the presence of email firewalls prevented the assessment of how many potential respondents received the recruitment notice. Potential respondents were emailed five times over a period of three months. Of the people reached, 610 began the web-based survey but only 369 (60%) completed the study measures and demographic information to a sufficient extent for inclusion as a participant. We used this particular sampling method to identify practicing counselors affiliated with ACA and its divisions and branches. We aimed to generalize results of the current study to the ACA community, comprised of a diverse national and international group of practicing counselors and very similar groups. We also used an incentive raffle to encourage participation, and participants had the opportunity to win one of two $25 electronic gift cards.
Demographic information form. The demographic information form was administered to obtain information about the participants’ ethnicity, age, gender, educational background, years of counseling experience, specialty area, current position, consultation training, supervision training, and experiences of consultation and supervision.
CSS. Moe et al. (2018) developed the CSS to assess counselors’ awareness of consultation theory and related consultation skills. In the CSS, Moe et al. aimed at differentiating consultation from other areas of practice, while keeping the focus applicable across counseling specialties. The CSS’s specific focus on consultation practice supports the evaluation of training and practice in consultation as a distinct modality relative to other professional counseling practice domains. With a sample of 145 counseling professionals and interns, Moe et al. conducted an EFA on the 19-item CSS using a maximum likelihood extraction with direct oblimin rotation. In the preliminary analysis, the unrotated solution for the EFA revealed two factors; however, a single-factor structure with 17 items appeared as the most robust solution for the CSS. Indicating validity, the CSS was positively associated with counseling experience and sexual orientation competence, and the Cronbach’s alpha coefficient for the total scale was reported as .97. The CSS utilizes a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). In the present study, the Cronbach’s alpha coefficient for the 17-item CSS was .98.
Supervisory Working Alliance Inventory – Supervisor (SWAI-S). Participants’ perceptions of being able to establish a working alliance in counselor supervision were assessed with the Supervisory Working Alliance Inventory – Supervisor Scale (SWAI-S; Efstation, Patton, & Kardash, 1990). The SWAI-S is a 23-item, 7-point Likert scale ranging from 1 (almost never) to 7 (almost always). Client Focus, Rapport, and Identification are the three domains that comprise the overall items on the SWAI-S. The Client Focus domain emphasizes the supervisor’s contribution to the supervisee’s perception of the client. Rapport stresses the supervisor’s effort in the supervisory rapport-building process, and Identification draws attention to the supervisor’s view of the supervisee’s identification in the supervision process. Efstation et al. (1990) reported alpha coefficients for SWAI-S subscales as .71 for Client Focus, .73 for Rapport, and .77 for Identification. In the current study, we found alpha coefficients for SWAI-S subscales as .98 for Client Focus, .99 for Rapport, and .99 for Identification. Convergent and divergent validity of the scales were established through intercorrelations with the Supervisory Styles Inventory (Efstation et al., 1990). For the purposes of the current study, participants were asked to indicate the extent to which SWAI-S items were characteristic of their work with trainees during their supervision.
Modified Index for Interdisciplinary Collaboration (MIIC). Participants’ perceptions of collaboration on interdisciplinary teams were measured with the Modified Index for Interdisciplinary Collaboration (MIIC; Oliver, Wittenberg-Lyles, & Day, 2007). The MIIC is a 42-item self-report questionnaire with a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Including four subscales of Interdependence and Flexibility, Newly Created Professional Activities, Collective Ownership of Goals, and Reflection on Process, the MIIC’s conceptual framework is based on the original instrument, the Index for Interdisciplinary Collaboration (IIC; Bronstein, 2002); therefore, it is expected to have the same face validity with the IIC (Oliver et al., 2007). The internal consistency estimate of the MIIC, calculated as Cronbach’s alpha, was found to be .94 for the present study. The subscale internal consistency estimates were found to be .87 for Interdependence and Flexibility, .77 for Newly Created Professional Activities, .80 for Collective Ownership of Goals, and .79 for Reflection on Process (Oliver et al., 2007). For the purposes of our current study, participants were asked to specify their agreement on the MIIC statements with regards to their current primary work setting and organization.
Data Screening and Analyses
Confirmatory Factor Analysis (CFA). To examine the fit for the single-factor solution of the CSS in our sample, we utilized Mplus 6 to run a CFA. Prior to conducting the analysis, we initially examined the necessary assumptions for the CFA (i.e., multivariate normality; Kline, 2011). We observed 26 cases as multivariate outliers in our sample. Upon the examination of these cases’ influence on our results with and without them, we decided to remove these outliers from the final analysis. To have a robust understanding of our CFA results, we observed multiple fit indices for the single-factor model from Moe et al.’s (2018) EFA (i.e., chi-square test, root mean square error of approximation [RMSEA], confirmatory fit index [CFI], and standardized root mean square residual [SRMSR]), as recommended by Lent, Lopez, Brown, and Gore (1996).
Other validity analyses. We also examined convergent, divergent, concurrent, and incremental validity psychometrics of the CSS. We first explored the correlations between the CSS and the subscales of the SWAI, namely Client Focus (CF), Rapport (R), and Identification (I), for the convergent validity—as they measured similar, but not identical concepts. To explore divergent validity, we checked the correlations between the CSS, the MIIC, gender (identifying as male), and ethnicity (identifying as European American)—as all measured different concepts. Next, concurrent validity of the CSS was investigated through the examination of mean differences between participants without consultation training, those with one to two consultation training experiences, and those with three or more consultation training experiences. Finally, we tested incremental validity of the CSS via a hierarchical regression analysis in which predictive ability of the CSS was examined to predict participants’ MIIC scores beyond the variables of age, gender, and years of experience.
Reliability analyses. Finally, we examined Cronbach’s alpha coefficient as well as split-half reliability properties of the CSS for internal reliability.
In our sample, the CFA fit indices for the single-factor model yielded a poor model fit for single-factor solution. Specifically, although non-significance is desirable (Tabachnick & Fidell, 2013), we obtained a significant result for the chi-square test of model fit. This test is known as sensitive to sample size (Lent et al., 1996), and to account for this, we continued with examining other criteria for our model fit. We also obtained initial values for RMSEA (.12) and CFI (.90) outside the recommended criteria for fit (RMSEA < .06, CFI > .95; Hu & Bentler, 1999). The SRMSR was the only index meeting the recommended fit criteria (.04 < .08; Hu & Bentler, 1999). After this initial review, we followed Cole and Maxwell’s (2003) recommendations on examining modification indices. As a result of conducting necessary modifications, we removed nine items from the CSS, and the CFA results revealed a better fit for an 8-item version of the instrument the authors called the Consultation Skills Scale-Short Form (CSS-S; χ2(28) = 86.21, p = .00, CFI = .98, RMSEA = .075, 90% CI [.06, .90], SRMSR = .02). See Table 2 for means, standard deviations, and factor loadings of the eight items.
Means, Standard Deviations, and Factor Loadings of the Items of the CSS-Short Form
||I know how to help consultees improve programming issues for work with identified clients.
||I know how to develop a consultation contract.
||I know how to apply established problem-solving models to address consultee concerns.
||I am familiar with systems consultation.
||I know how to operate as an external consultant.
||I know how to operate as an internal consultant.
||I know how to assess the culture and climate of consultee organizations.
||I can address theme interference effectively with consultees.
a Means are based on a scale of 1 to 5.
We obtained initial evidence for the construct validity of the CSS-S through our CFA results. Convergent validity of the CSS-S was established through the obtained significant correlation coefficients between the CSS-S and SWAI-CF (r = .50), SWAI-R (r = .46), and SWAI-I (r = .46). Indicating divergent validity for the CSS-S, the correlation coefficients between the CSS and the MIIC, gender, and ethnicity were .34, .05, and -.03, respectively. The results of a one-way ANOVA indicated concurrent validity for the CSS-S with significant differences between the three groups of participants without consultation training, those with one to two consultation training experiences, and those with three or more consultation training experiences: [F(2,368) = 28.27, p = .00]. Participants with three or more consultation training experiences reported significantly higher consultation practice proficiency perceptions (M = 38.39, SD = 6.40) when compared to participants without consultation training (M = 26.47, SD = 8.96) or with one to two consultation training experiences (M = 32.62, SD = 9.67). Finally, showing incremental validity, the CSS-S also explained an additional 7% of the variance in participants’ MIIC scores (R2 = .132, p = .000), above and beyond the independent variables in the first (i.e., age, gender, and years of experience; R2 = .004, p > .05) and second (i.e., SWAI; R2 = .058, p = .000) blocks.
The reliability analyses results showed satisfactory support for the CSS-S. For the present study, Cronbach’s alpha coefficient for the CSS was .96; no items appeared to reduce the reliability coefficient of the scale. We also examined the Spearman-Brown coefficient for the split-half reliability and obtained .96.
In this study, we obtained strong results for the single-factor structure as well as validity and reliability properties for a shorter version of the CSS-S in a sample of counselors. Our results also revealed further validation for consultation as a distinct area of practice.
Psychometric Qualities of the CSS-S
CFA results revealed that the CSS-S is a psychometrically sound unidimensional instrument, measuring counselors’ consultation skills as a distinct modality relative to other professional counseling practice domains. In the current sample, upon poor fit of the initial single-factor solution, we further utilized modification indices and eliminated items. As a result, different than the original 17-item instrument (Moe et al., 2018), we obtained a shorter version of the CSS with eight items indicating a good CFA solution fit.
We further obtained significant results for the CSS-S via convergent, divergent, concurrent, and incremental validity procedures. For convergent validity, we found that counselors’ CSS-S scores were moderately related to the subscales of the SWAI (i.e., Client Focus, Rapport, and Identification). These relationships revealed that the CSS-S measured a similar but different competency area compared to the area of supervision. We also found that counselors’ CSS-S scores were unrelated to gender or ethno-cultural identification and were weakly related to the MIIC, establishing divergent validity. In other words, counselors’ consultation skills were distinctly different than their gender or ethno-cultural identification and separate from their interdisciplinary collaboration ability. Supporting concurrent validity, counselors’ CSS-S scores got higher as they had more consultation training (i.e., three or more consultation training experiences vs. one to two or no consultation training experiences). Beyond other variables (i.e., years of experience and supervisory working alliance), counselors’ consultation skills significantly contributed to their interdisciplinary collaboration ability, indicating incremental validity of the CSS-S.
Finally, we examined the reliability of the CSS-S by observing the internal consistency across the items. Both Cronbach’s alpha and split-half reliability results were strong, demonstrating satisfactory results for the CSS-S. The CSS-S appears to possess useful validity and reliability characteristics for assessing counselors’ perceptions of their own abilities to practice consultation and may help scholars develop more empirically grounded scholarship on consultation as a distinct mode of practice.
Consultation and Supervision as Related and Distinct Areas of Practice
In addition to validation of the CSS-S, our findings also point out other significant information. The domains of consultation and supervision have long been conceptually linked in the literature, primarily in terms of both serving as modalities for senior clinicians to provide support and mentorship to their colleagues (Truneckova, Viney, Maitland, & Seaborn, 2010). The consultation paradigm of consultee-based mental health consultation (Newman & Ingraham, 2017) shares similarities to clinical supervision in terms of a shared focus on promoting skill development in consultees or supervisees to work with an identified client population or presenting problem. In the Discrimination Model, consultation is presented as one of the roles of clinical supervisors while training professional counselors (Bernard & Goodyear, 2018). According to the Discrimination Model, supervisors’ engagement in a consultative, collaborative relationship is seen as a hallmark of supervisee development, in which the supervisee is invited to contribute as a peer and fellow professional expert (Bernard & Goodyear, 2018). From their phenomenological study of the supervisory relationship between female supervisors and supervisees, Mangione, Mears, Vincent, and Hawes (2011) also reported that consultation emerged as an important theme when participants reflected on how to create a collaborative environment during the supervision process. Adopting the role of consultant may enhance the supervision process for counselors-in-training (Sangganjanavanich & Lenz, 2012). For example, Granello, Kindsvatter, Granello, Underfer-Babalis, and Moorhead (2008) identified peer consultation as an intervention for promoting perspective taking and overall cognitive development in supervisees. The relationships between the counselors’ perceptions of their consultation skills and supervisory working alliance in the current study were indications of the complementary relationship between counseling professionals’ consultation and supervision roles. Our findings appear to promote the understanding that although consultation skills and different dimensions of supervisory work are intertwined, they are also distinct concepts, and expertise in one modality does not necessarily ensure expertise in the other.
The current study involved limitations that need to be reported. First, we specifically targeted counseling professionals in this study and did not include participants from other fields. Another group of counselors or participants from other fields (e.g., social work, nursing) may have yielded different results than the ones we obtained in this study. Second, we did not examine some of the specific demographic variables (e.g., specialty areas, position) within our data set. Those variables may have influenced the results of the current study. Lastly, despite being part of a master list of licensed counselors, self-selection of our participants in this study could indicate participants’ interest in consultation as an area of practice. The authors may not have reached out to enough participants who lacked knowledge and experience of consultation, or had sufficient participants with experience as a supervisor to effectively complete the SWAI-S.
Implications for Future Research and Practice
Our results supporting the psychometric qualities of the CSS-S have both research and practical implications, many of which are connected to one another. The lack of a psychometrically sound measure of counselors’ consultation skills has limited research on consultation efficacy in the counseling literature and the research base of other helping fields (Dougherty, 2013). Assessing counselors’ perceptions of their consultation skills with the CSS-S can help to clarify and contribute to consultation efficacy research in counseling and counselor education. The small number of items on the CSS-S also offers researchers the convenience of a brief measure for participants to self-assess their consultation skills and can help clarify how this construct influences other areas of counseling practice. For example, the CSS-S may be used with participants from different specialty areas of counseling (e.g., school counseling, mental health counseling) and different professional development levels (e.g., counseling interns, counselors working toward licensure, licensed counselors) to understand the participants’ consultation skills perceptions and their potential needs. Researchers also could utilize the CSS-S to address the need for examinations of consultants’ relative competence to practice consultation from a theory-based foundation. The CSS-S could address the gap between consultation training, practice, and research. Particularly, as counselors and counselor educators prepare to operate in a modern clinical environment, where behavioral and physical health care professionals are encouraged and expected to collaborate effectively, assessing counselors’ consultation abilities could help support development of the skills necessary to operate within the integrated care paradigm. Similarly, because of the generic language of the instrument, researchers could establish the validity and reliability properties of the CSS-S with samples from other fields (e.g., social work, nursing). In these efforts, researchers also could compare professionals from different fields (e.g., counseling vs. nursing) to examine similarities and differences among the participants’ consultation skills perceptions as well as other variables (e.g., consultation training and practice experiences), and explore the discipline-specific factors that may influence how consultation is practiced and when it is considered to be an effective intervention.
Researchers have identified the process nature of consultation as an impediment to establishing the efficacy of consultation (Erchul & Sheridan, 2014). Consultants’ ability to practice consultation as a distinct helping intervention is both a process and outcome variable, and a valid measure of this construct can help to establish baseline levels of consultant ability or serve to identify when during the consultation relationship a consultant feels most capable. In tandem, counselor education programs could use the CSS-S as a baseline instrument to identify relative levels of familiarity with the consultation paradigm and tailor their consultation-related pedagogy to the needs and expectations of counselor trainees with different levels of consultation proficiency. Being able to assess consultation proficiency also can help to clarify when and what types of training are most effective. Questions related to where in the curriculum this domain should be introduced, what methods are optimal for ensuring retention and mastery, and what benchmarks exist for the development of consultation skills can be explored empirically with the measure presented in this study.
We presented the results of a psychometric investigation of the CSS-S, a derived measure assessing participants’ perceptions of their skills to practice consultation as a distinct modality based on specific knowledge and skills. The preliminary findings demonstrate support for continued use of the CSS-S in research on consultation and support previous conceptual scholarship identifying consultation as complementary to but also distinct from clinical supervision and interprofessional collaboration. Training in consultation (i.e., coursework, supervised experience, postgraduate workshop attendance) appeared to increase participants’ perceptions of consultation skills as measured with the CSS-S. Consultation is a distinct mode of counseling and behavioral health practice, and being able to assess consultants’ perceptions of their own abilities is an important step in advancing the research base on consultation theory and how this domain can be employed to promote better outcomes for clients, students, and communities, not only in educational and clinical settings, but also in integrated health care settings.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Gulsah Kemer, NCC, is an assistant professor and graduate program director at Old Dominion University. Jeffry Moe, NCC, is an associate professor at Old Dominion University. Kaprea F. Johnson is an associate professor at Virginia Commonwealth University. Emily Goodman-Scott, NCC, is an associate professor and graduate program director at Old Dominion University. Zahide Sunal is a doctoral student at Old Dominion University. Chi Li, NCC, is an assistant professor at the University of Memphis. Correspondence can be addressed to Jeff Moe, ODU Counseling and Human Services, 2106 New Education Building, Norfolk, VA 23529, email@example.com.