trust - The Professional Counselor

Experiences of Cross-Racial Trust in Mentoring Relationships Between Black Doctoral Counseling Students and White Counselor Educators and Supervisors

Sep 10, 2019 | Volume 9 - Issue 3

Eric M. Brown, Tim Grothaus

The literature is replete with research and references to racism experienced by Black faculty and students in counselor education. Although explorations of the mistrust in relationships between races is extant, empirical investigations into trusting cross-racial relationships in counselor education have been scarce. To address this void, the researchers conducted a phenomenological qualitative study with 10 Black doctoral counseling students concerning their experiences of cross-racial trust with White counselor educators and clinical supervisors who were mentors. Researchers identified three superordinate themes during data analysis: reasons for trust, reasons for mistrust, and benefits of cross-racial mentoring. The researchers also identified several themes and subthemes that delineated the interpersonal and intrapersonal factors that helped generate cross-racial trust, despite participants’ ubiquitous experiences of racism. The participants’ experiences are discussed, and implications are offered for enhancing trust in cross-racial relationships in mentoring, supervision, counseling, and training programs.

Keywords: cross-racial, trust, supervisors, mentors, counselor educators

The counseling profession purports to value racial inclusivity, cultural competence, and social justice (e.g., American Counseling Association [ACA], 2014; Council for Accreditation of Counseling and Related Education Programs [CACREP], 2015; Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015). Yet, this vision remains unrealized. Black counselor educators and students report that White racism is pervasive (Baker & Moore, 2015; Brooks & Steen, 2010; Henfield, Woo, & Washington, 2013; Holcomb-McCoy & Addison-Bradley, 2005). Although empirical studies have documented the negative experiences of Black people within counselor education because of the prevalence of racism (Baker & Moore, 2015; Cartwright, Avent-Harris, Munsey, & Lloyd-Hazlett, 2018; Haskins et al., 2013; Henfield et al., 2013), research regarding positive interracial relationships, specifically involving successful Black–White mentoring connections, has been scarce (Fleig-Palmer & Schoorman, 2011; Leck & Orser, 2013). Our study sought to address this inequity and incongruence by using a strength-based lens to explore successful, trusting, cross-racial mentoring relationships.

Racism in Counselor Education

Baker and Moore’s (2015) qualitative study examined the experiences of 19 ethnic minority doctoral students in counselor education, 12 of whom were Black. The student participants voiced their frustrations with the pressures they felt to suppress their ethnic identity and to act in ways aligned with White cultural standards. Although Henfield et al.’s (2013) phenomenological study of 11 Black doctoral students found a desire for mentoring from faculty members, the students shared similar conclusions regarding their isolation and disconnection from the faculty in their programs. This appeared to mirror the experiences reported by Black faculty. Holcomb-McCoy and Addison-Bradley (2005) found Black counselor educators did not feel included as valuable assets by their White colleagues. Finally, a study of 11 Black doctoral counseling students by Henfield, Owens, and Witherspoon (2011) revealed that despite feeling marginalized, their participants used relational resources, such as peer support, race-based organizations, and personal and professional advisors, to promote their success. Together, these studies expose a pernicious incongruence between what the counseling profession champions and what Black students and faculty are experiencing. One promising means of ameliorating these concerns could be culturally responsive cross-racial mentoring, which may assist in bridging this gap (Alvarez, Blume, Cervantes, & Thomas, 2009). In particular, cross-racial mentoring has been viewed as an avenue to enhance the recruitment and retention of counselor education faculty of color (Borders et al., 2011; Butler, Evans, Brooks, Williams, & Bailey, 2013).

Cross-Racial Mentoring

Blackwell (1989) defined mentoring as “a process by which persons of superior rank, special achievements, and prestige instruct, counsel, guide, and facilitate the intellectual and/or career development of persons identified as protégés” (p. 9). Positive mentoring can be an asset and also an antidote to the bigotry and marginalization often experienced by students of color (Luedke, 2017; D. L. McCoy, Winkle-Wagner, & Luedke, 2015). Effective mentoring also can enhance students’ likelihood of academic and career success and professional growth, along with increasing self-efficacy, mental health, and social and cultural capital (Chadiha, Aranda, Biegel, & Chang, 2014; Chan, Yeh, & Krumboltz, 2015; Gaddis, 2012; Hurd & Zimmerman, 2014).

Although students of color often desire mentoring from ethnic minority faculty, there is a need for cross-racial mentoring because of the lack of faculty of color (Brooks & Steen, 2010; Ortiz-Walters & Gibson, 2005; Patton, 2009). Yet, some scholars (Johnson-Bailey & Cervero, 2004) note that cultural mistrust may hinder the forming of these beneficial interracial relationships, thus denying many Black graduate students the professional and psychological benefits associated with mentoring.

Cross-Racial Trust and Mistrust

For successful mentoring, a trusting relationship appears to be vital (Chan et al., 2015; Chun, Litzky, Sosik, Bechtold, & Godshalk, 2010; Eller, Lev, & Feurer, 2014; Gaddis, 2012; D. L. McCoy et al., 2015; Merriweather & Morgan, 2013; Rademaker, Duffy, Wetzler, & Zaikina-Montgomery, 2016). Yet, in the United States, the largest gap in cross-racial trust is between Black and White people (S. S. Smith, 2010).

As a result of both the long history and current experiences of racism in America, cultural mistrust, or the mistrust of White people by ethnic minorities, may serve a psychologically adaptive function in affording self-protection (Bell & Tracey, 2006; Terrell & Terrell, 1981; Whaley, 2012). Black people rate highest in cultural mistrust of all major ethnic minority groups, which may be a result of the particular history of slavery and the oppressive practices that continue to this day. Although cultural mistrust can serve as a protective factor, Bell and Tracey (2006) found that Black patients with higher levels of cultural mistrust suffered psychologically. Another effect of high levels of mistrust may be a lack of desire for Black people to build alliances with White professionals of goodwill who can assist with their professional development (Johnson-Bailey & Cervero, 2004). Although additional studies examining racism and its impact on the professional development of students of color are needed, the more conspicuous gap in the literature is with regard to cross-racial trust and positive cross-racial relationships.

With the disproportionate underrepresentation of Black faculty in counselor education, it is likely that some Black graduate students will need to connect with White mentors (Brooks & Steen, 2010; Haizlip, 2012). Although multiple studies have examined the challenges experienced by Black students in counselor education programs (Baker & Moore, 2015; Haskins et al., 2013; Henfield et al., 2013), there is a dearth of explorations of trust in the counseling literature, especially cross-racial trust. Our phenomenological study addresses this omission by investigating successful Black–White trusting mentoring relationships in counselor education.

The goal of our study was to examine Black doctoral counselor education students’ experiences of cross-racial trust with White mentors in the counseling profession. The results of this study may encourage Black students to consider seeking mentoring relationships with White individuals, given the relative shortage of racial minorities within the profession, and also help White people of goodwill to mentor and aid Black students in achieving their academic and professional goals.

Methodology

In order to explore and represent the lived experiences of Black students’ successful cross-racial mentoring relationships in the counseling profession, the first author conducted a qualitative study in the tradition of transcendental phenomenology with Black doctoral counseling students who had trusting relationships with White mentors in the profession (Moustakas, 1994). Phenomenological research focuses on the lived experiences of people, amplifying their voices as it seeks to ascertain the meanings they give to their experiences (Adams & van Manen, 2008). Through this lens, we examined the experiences of 10 Black doctoral counseling students who participated in at least one trusting cross-racial relationship with a White mentor.

Our study was guided by the following research question: What are the lived experiences of Black doctoral students who have participated in or are currently in trusting relationships with White mentors within the counseling profession?

Researcher Bias

Researcher bias may threaten the validity of qualitative research conclusions. All research team members bracketed their assumptions through recording their expectations before the interviews and via ongoing conversation throughout data analysis (Gearing, 2008). The primary researcher was a Black middle-class male doctoral counselor education student who conducted this study for his dissertation. His ethnicity and student status qualified him as an insider in relation to the participants (Tinker & Armstrong, 2008). His a priori assumption was that participants would be more inclined to trust White people who acknowledged present-day racial injustices. The research team included two doctoral counselor education students, a White female and a White male, who had each completed at least one doctoral-level qualitative research course. Both research team members believed Black students would trust White people who showed unconditional positive regard. A White male counselor educator with a record of published qualitative research served as the independent external auditor. The research team also utilized reflective journaling and consensus coding to manage and reduce researcher bias.

Participants

The purposive sample of participants was recruited from the lead researcher’s informal network of doctoral counselor education students and faculty (who recommended possible participants). Selection criteria included being a Black doctoral counselor education student who had one or more trusted White mentors within the counseling profession. Each participant was given the definition of mentoring used by the primary researcher (Blackwell, 1989). A total of 10 doctoral students in counselor education expressed interest, met the criteria, and were interviewed for our study. This falls within the range of three to 10 participants recommended by Creswell (2014).

Five participants identified both a White professor(s) and a clinical supervisor(s) they trusted. Three identified at least one professor, and two identified at least one supervisor. See Table 1 for demographic information regarding the participants and the role of their mentor.

Table 1

Participant Demographic Information

Gender	Age Range	Ethnic Undergrad	Research Level PhD Program	Area/Location Raised	Socio-Economic Status	Parents’ Education	How Many Mentors	Position of Mentor
Male	20s	HBCU	2	Urban/ Northeast	Working Class	FGG	One for 3 years	Professor
Male	20s	PWI		City/ Southeast	Working Class	FGG	Five between 1–5 years	Professors/ Supervisors
Male	20s	PWI	3	Urban/ Midwest	Working Class	CGG	Two for 2 years	Professor/ Supervisor
Male	20s	PWI	1	Urban/ Midwest	Working Class	CGG	Two for 3–4 years	Professor/ Supervisor
Female	50s	HBCU	2	Suburban/ Mid-Atlantic	Middle Class	FGG	Two for 3 years One for 10+ years	Supervisors
Female	20s	PWI	2	Urban/ Mid-Atlantic	Middle Class	FGG	Three for 2–3 years	Supervisors
Female	30s	PWI		Suburban/ Southeast	Working Class	FGG	One for 8 years	Professor
Female	20s	PWI	2	Suburban/ Mid-Atlantic	Working Class	CGG	Three for 1–2 years	Supervisor/ Professor
Female	20s	PWI	2	Appalachian/ Midwest	Poor	FGG	One for 1 year	Professor
Female	30s	MSI	2	Suburban/ Southeast	Working Class	FGG	One for 10 years One for 1 year	Supervisor/ Professor

Note.	CGG = Continuing Generation College Graduates	MSI = Minority-Serving Institution
	FGG = First Generation College Graduates	PWI = Predominately White Institution
	HBCU = Historically Black College/University

Procedure

Subsequent to receiving IRB exempt approval from the authors’ college review board, the primary researcher sent an introduction letter explaining the study via email to counselor education faculty and doctoral students with whom he was familiar through professional networking. Once consent was obtained, the lead researcher sent the demographic questionnaire and the interview questions to participants 48 hours before their interviews in order to provide time to reflect about their experiences (James, 2014). The protocol was constructed by the authors based on pertinent literature related to trust and ethnic minority experiences and reviewed by a team of three counselor educators. The primary researcher then conducted semi-structured interviews focused on the participants’ experiences of cross-racial trust. Interview questions included: (a) Can you please describe experiences in your past that enabled you to trust a White person as a mentor? (b) What did you experience within this cross-racial relationship(s) that enabled you to trust this White mentor? and (c) Can you share the differences between the Whites you chose to trust and those that you trusted less? Initial interviews ranged from 30 to 60 minutes and were conducted by the primary researcher either face-to-face or via a secure connection on Adobe.

A professional transcriptionist confidentially transcribed each interview. Each participant received a copy of the transcript for member checking (Creswell, 2014). The lead researcher also conducted a follow-up interview to allow participants to add or revise anything that was said in the initial inquiry. Eight of the 10 doctoral students participated in follow-up interviews, which lasted between 10 and 20 minutes. The two participants who declined stated they had nothing further to add.

Data Analysis

The research team employed Moustakas’ (1994) data analysis process for each transcript, beginning with horizontalization, which included noting individual meaning units and holding them with equal importance. The team then engaged in reduction and elimination of meaning units based on redundancy, and also whether they were “necessary . . . for understanding the phenomena” (Moustakas, 1994, p. 120). The team members individually categorized remaining meaning units related to the phenomena and identified clusters and themes from the data. After independently analyzing transcripts, the research team met after the first two interviews to ensure fidelity in the coding process, and again after the eighth and 10th set of interview transcripts were coded. They came to a consensus regarding whether each code had sufficient support based on textural descriptions; then they created a final code book (Hays & Singh, 2012). The research team also engaged in a deviant case analysis to honor the diverse phenomena represented amongst participants. Next, the team utilized textural-structural descriptions from the transcripts to illustrate codes and themes identified in the data.

Trustworthiness refers to the accurate reflection of the participants’ voices and perspectives (Given & Saumure, 2008). In this study, trustworthiness attributes included credibility, confirmability, transferability, and dependability (Lincoln & Guba, 1985). In an effort to secure trustworthiness, the research team utilized Moustakas’ (1994) process of analysis, reflective journals, consensus coding, member checking, follow-up interviews, use of an external auditor, and providing thick descriptions of the research process and participants.

Results

The research team identified three superordinate themes from the data: reasons for trust, reasons for mistrust, and benefits of cross-racial mentoring.

Superordinate Theme One: Reasons for Trust

All 10 of the participants identified factors that fostered their willingness to engage in a cross-racial trusting relationship with White mentors, which provided the basis for this superordinate theme. We identified four themes from the participants’ data: past experiences, trusting by proxy, personal attributes, and the necessity of White people.

Past experiences. Data from nine participants supported this theme and its two subthemes: experiencing positive relations with White people and experiencing rejection from Black people.

Experiencing positive relations with White people. Half of the participants shared experiences illustrating how White people had proven themselves to be trustworthy. For example, participants spoke of experiencing White people who married into the family or who were part of their experience being raised in a multiracial church, and of having White coaches and teachers who invested in them personally during key developmental stages in their life. The investment of time and emotional resources from these White people established a sense of safety and trust during their younger years. These relationships helped to provide the experiential and emotional base for the risk of cross-racial trust.

Experiencing rejection from Black people. Four participants shared negative past experiences with Black people, involving peers, professors, supervisors, or former employers, which led them to be hesitant to trust Black people—opening the door to choosing White people as possible mentors. One female participant shared that she had not felt welcomed by some Black women in the profession. A male participant spoke of being mocked in childhood for not being “Black enough” and his subsequent struggles: “It was actually heart-wrenching for me to recognize that I’m not comfortable being in a room full of Black people. . . . I was always worried about being, even in a professional setting, being outed as, ‘Oh well, he’s Black, but he’s not really.’” All four participants exhibited reticence about sharing these experiences and the accompanying feelings of frustration, shame, and isolation.

Trusting by proxy. Half of the participants shared that they would consult with Black colleagues when discerning whether a White person may be trustworthy. These students trusted their Black peers, seeking their opinions concerning which White professors and clinical supervisors could be trusted. One shared the importance of having friends indicate, “You can trust this person…they get it.”

Personal attributes. This refers to personal attributes or qualities of the participants themselves that enabled trust in White people. The two subthemes identified were being generally trusting and being courageous.

Being generally trusting. Five participants shared that they were generally trusting and therefore willing to give all people a chance. These students believed their generally trusting nature helped them be open to the possibility of a cross-racial trusting relationship.

Yet, not all participants described themselves as generally trusting. One doctoral student shared his cautious and guarded nature toward people regardless of race. He indicated that he chooses to observe people over time in order to discern whether they are trustworthy.

Being courageous. Two participants noted that courage is needed to engage in cross-racial trust. They were cognizant of the vulnerability that interracial trust entails for the protégé and spoke to the emotional resilience needed for a Black person to pursue and then persist in a Black–White mentoring relationship. All 10 participants spoke of the reality of racism in their lives and in their counselor education programs. Therefore, Black students who attempt to develop a cross-racial trusting relationship are exposing themselves to the possibility of further injury and experiences of bigotry and marginalization.

Necessity of White people. Four participants shared their understanding from a young age that Black people would likely need relationships with White people if they were to succeed academically or professionally. White mentors can help serve as a guide to navigating predominately White systems. Therefore, achieving success as a Black person necessitated placing oneself in a precarious position. These students believed that one must have positive relationships with White people even though most White people are not trustworthy.

Superordinate Theme Two: Reasons for Mistrust

All 10 participants spoke about reasons they had for mistrusting White people. Four themes describe the various causes for Black mistrust of White people: receiving family messages, experiencing overt racism, experiencing tokenism, and experiencing dissonance.

Receiving family messages. Participants spoke of learning cross-racial mistrust through observation and receiving direct messages from family members. There were two subthemes under family messages: overt messages and White voice.

Overt messages. Half of participants shared that they heard messages since childhood from family members that White people are untrustworthy. One interviewee’s parents told him he could not have White friends; other participants were explicitly told by family members that White people were not to be trusted. Yet, this was not true for all participants. One student recalled “I was constantly told ‘you can have people around you, but just don’t trust the White people that are around you’ . . . [but] some Whites are trustworthy.” Yet, as he grew older, his parents began to discuss the realities of racism and navigating life as a Black male.

White voice. Two participants shared implicit messages they witnessed while growing up, such as noticing that Black people would change their dictation and mannerisms when interacting with White people. One participant shared that “we used to just call it the White voice . . . around professional people who they weren’t super comfortable with.” As children, these participants observed their families codeswitching and understood implicitly that Black individuals cannot be themselves around White professionals.

Experiencing overt racism. Five participants described past racist experiences with neighbors, educators, and police that hindered their willingness to engage in cross-racial trust. Some students shared stories from childhood; others noted more recent occurrences. One male interviewee reported that he had been pulled over several times by White police officers as a teenager but only received one ticket, which he believed showed the lack of justification White police had for pulling him over. He also told the story of a police officer pulling a gun on him and his friends while he was in his car. All such experiences confirmed the explicit and implicit messages they received from their families concerning White people being untrustworthy.

Experiencing tokenism. Five participants stated that they were suspicious of White counseling professionals’ motives for desiring a relationship. One female student stated she wonders if White people are trying to make up for a racial injustice they committed in their past, stating, “I definitely am a little hesitant to see what’s your true motive.”

Other participants questioned the motives of White people who want to build a professional relationship with Black people. One interviewee said he felt “commodified” by White counseling professionals. He reported feeling put in a box as “the Black male counselor” who works with trauma. Another participant felt used by a White professor who she believed wanted her participation to give validity to a presentation on a multicultural topic at a conference.

Experiencing dissonance. Several participants spoke about internal conflicts that stemmed from their experience in the predominately White field of counseling. Four subthemes emerged from this data: internalizing racism, feeling isolated, questioning one’s perception, and considering White trust.

Internalizing racism. Two male participants shared distressing thoughts about their place in the counseling program, which stemmed from internalized racism. One participant shared that at times he did not feel equal to his White peers although objective measures demonstrated they were not superior to him intellectually or clinically. Although both Black male participants who shared these insecurities seemed poised and self-confident, they experienced self-doubts they attributed to internalized oppression.

Feeling isolated. Three participants shared that they felt isolated, either in their master’s or doctoral programs. One participant noted, “I’m that one student who brings up race, and who brings up people of color, and anybody who’s not White, and our issues in counseling, and none of my cohort does that.” These participants expressed frustration with fellow students, including people of color, who were unwilling to share their experience in class.

Questioning one’s perception. Two participants discussed periodically questioning their perceptions of racism, whether it actually occurred or if it was their own issue that they were imposing on White faculty and students in their department. One participant shared this process of questioning with two Black alumni from his program and was reassured “It’s not just you. It’s not in your head. You’re not wiling out.” He believed that this reflexive process of questioning one’s perception is a burden that Black people often carry in White settings.

Considering White trust. Two participants believed it was important for trust to be mutual. One participant questioned whether White people would trust her as a Black person. These participants recognized that they could not trust White people who would not trust them.

Superordinate Theme Three: Benefits of Cross-Racial Mentoring

The final superordinate theme was voiced by nine participants and contained two themes: benefiting from networks of privilege and disconfirming over-generalizations of White individuals.

Benefiting from networks of privilege. Five participants noted that White mentors had helped them make professional connections or hoped that they would do so. They believed that White mentors have access to social networks that some Black faculty and supervisors do not and believed their White mentors could use their privilege and cultural capital on their behalf.

Disconfirming over-generalizations of White individuals. Finally, four participants shared that trusting their White mentor helped them to trust other White people. One participant shared, “It helps me as a Black woman not to make these gross over-generalizations about White people, about White men in academia, about White counselor educators.” A few participants indicated the cross-racial trust emboldened them to branch out into new areas professionally and personally as a result of being more willing to build relationships with White people of good will.

Discussion

To help diversify the counseling profession, scholars have noted the importance of mentoring students from underrepresented groups (Fleig-Palmer & Schoorman, 2011; Leck & Orser, 2013). Considering the disproportionately low representation of counselor educators and supervisors of color and the numerous benefits of mentoring (Chadiha et al., 2014; Chan et al., 2015; Hurd & Zimmerman, 2014), interracial mentoring provides a viable pathway to increasing access to this valuable resource and enhancing inclusion and diversity (Brooks & Steen, 2010; Patton, 2009). One significant hindrance to interracial mentoring relationships is cultural mistrust, which is a result of historical and present experiences of racism and marginalization (Johnson-Bailey & Cervero, 2004). This study addressed a gap in the literature regarding cross-racial trust by examining the experiences of Black doctoral counseling students who were successful in establishing trusting relationships with White mentors, providing a complementary perspective to the literature that details reasons for and costs of the mistrust of White people by Black people in counselor education.

Our results shed light on the perilous nature of interracial trust for these Black participants. Trust by its very nature entails vulnerability (Eller et al., 2014; Merriweather & Morgan, 2013). Furthermore, the misuse of power intrinsic in White racism makes interracial trust risky for Black students desiring mentors in predominately White institutions (D. L. McCoy et al., 2015). For example, despite the success that led them to their doctoral student status, the themes of internalizing racism and questioning one’s perception speak to the added vulnerability involved in interracial trust. In Gildersleeve, Croom, and Vasquez’s (2011) article, “Am I Going Crazy?!,” the authors found that questioning one’s perception of racism may be characteristic of the experience of many doctoral students from underrepresented ethnic groups. Given documented experiences of racism within counselor education (e.g., Baker & Moore, 2015; Henfield et al., 2013), the questioning of one’s experience of marginalization is compounded within counseling programs, despite the profession’s claims to have a multicultural and social justice emphasis. Unless we are ready to actively examine privilege and bias in our programs and enact effective, substantive, and systemic actions to address and remediate the embedded inequities, our profession’s aspirational language will be revealed to be hollow and hypocritical.

Despite experiencing racism in their counseling programs, these participants did co-create successful and beneficial cross-racial relationships. Participants shared factors that encouraged them to engage in trusting relationships with White mentors. Having a generally trusting nature, and also prior positive experiences with White people, may be intuitive findings, but experiencing rejection from Black people as an impetus for interracial trust appears to be unique to this study. Participants also discussed White allies being needed for success, with systemic issues of racism hindering Black people from relying solely on resources from their own community both in counselor education and outside the profession.

Our findings also highlight the collectivist sensibilities that influenced participants’ decisions to trust White people. Participants confirmed S. S. Smith’s (2010) description of cultural mistrust being taught to Black children by their parents as a protective factor to equip these students to deal with the racism experienced both within counselor education and in society. Despite experiencing the veracity of these familial warnings, some students engaged in trust by proxy, itself a collectivist practice, in order to lessen the risk of interracial trust.

Scholars have proposed the need for cross-racial mentoring because of the lack of faculty of color (Brooks & Steen, 2010; Haizlip, 2012; Ortiz-Walters & Gibson, 2005). Yet, even when faculty and supervisors of color are present, some Black students may desire to connect with White faculty or supervisors. Although Patton (2009) found that Black women preferred faculty mentors who shared their race and gender, four participants of the current study, two males and two females, experienced rejection from Black people, which opened the possibility of a White mentor. Though some doctoral students and faculty can view this as a form of internalized racism, the narratives shared spoke more to a fear of being rejected by one’s racial group. Although discouraging encounters with other Black people occurred in their past, participants spoke of negative experiences with Black supervisors or faculty within their counseling programs and clinical settings. Therefore, one should not assume that Black faculty or supervisors will be inevitably preferred as mentors by Black doctoral students and supervisees.

The themes of the necessity of White people and benefiting from networks of privilege captured participants’ beliefs that cross-racial mentoring helps Black students advance academically and professionally. Borders et al. (2011) suggested that women and people of color may need several mentors to help them meet the unique challenges of their professional and psychosocial development in a context that is often White- and male-dominated. This study’s participants were cognizant of the numerous benefits of mentoring (Bynum, 2015; Gaddis, 2012) and, more specifically, the particular benefits of having a White mentor (Ortiz-Walters & Gibson, 2005).

Implications for Counseling Training Programs

Racism continues to inform exploitive institutional and systemic norms, values, and policies ensuring that the privileged preserve their advantages (DiAngelo, 2018). While there has been a recent resurgence of more flagrant forms of racist expression in these tumultuous times, the insidious effects of less egregious forms of racial bias, such as blindness to or avoidance of the topic, are still prevalent (Oluo, 2018). In the academy, and in counselor education specifically, despite our aspirations to embody and enact cultural responsiveness and social justice, Black doctoral students continue to be subject to oppressive individual and institutional bias in terms of treatment, climate, and policies (ACA, 2014; Baker & Moore, 2015; CACREP, 2015; Henfield et al., 2013; S. Z. McCoy, 2018; Ratts et al., 2015).

One example or result of racism in graduate education is students of color having less access to the mentoring and social connections that positively impact educational and career opportunities (Rudolph, Castillo, Garcia, Martinez, & Navarro, 2015). An additional pernicious contributor to this inequity is the prevailing deficit narratives White faculty often hold about the abilities of students from non-dominant statuses (D. L. McCoy et al., 2015; S. Z. McCoy, 2018). Given the benefits of positive, trustworthy mentoring experiences and the disproportionately large representation of White counselor educators, cross-racial relationships hold promise if trust can be established (Baker & Moore, 2015; Cartwright et al., 2018; D. L. McCoy et al., 2015).

To generate conditions for more equitable and trusting mentoring relationships, our profession needs to vigorously promote the cultivation of cultural humility, signified by actions and attitudes reflecting respect, openness, genuineness, and curiosity (Davis et al., 2016; Hook, Davis, Owen, Worthington, & Utsey, 2013). This should be reflected in our standards for accreditation of training programs and licensure as counselors and supervisors. Specifically, White counselor educators and supervisors need to continuously examine and actively address their own, often implicit, racial biases (S. Z. McCoy, 2018). In addition, the existing oppressive climate in our profession, our preparation programs, and the society at large needs to be met with active social justice advocacy for, by, and with our students, protégés, and clients. These efforts will include addressing racism and microagressions promulgated by people and policies (ACA, 2014; Davis et al., 2016; Ratts et al., 2015). As has been noted, if we are not actively advocating for solutions, we are promoting the inequitable status quo.

In addition, we need to seek, invite, and include extraordinary strengths, wisdom, and capital possessed by students and clients of color in our programs and counseling and supervision sessions. Appreciation and incorporation of these assets would invite more reciprocal and culturally responsive relationships (Butler et al., 2013; Chadiha et al., 2014; Rudolph et al., 2015). Finally, specifically with mentoring relationships, being open to a more holistic relationship including important personal (e.g., experiences of oppression) and professional concerns is supported in the literature (e.g., Chan et al., 2015; Henfield et al., 2011). White mentors are invited to be proactive in seeking and cultivating relationships in which mutual learning is expected and discussion about racism and oppression is safe and welcome (Luedke, 2017; D. L. McCoy et al., 2015).

Transformational efforts should include encouraging and expecting culturally relevant pedagogy that fosters critical thinking and reflexivity, integrates cultural strengths as valued resources, and promotes proficiency for effecting social change (Gay, 2018; Motulsky, Gere, Saleem, & Trantham, 2014; Spanierman & Smith, 2017). For example, recognizing oppression at a structural level is associated with enhanced social justice commitment and less blaming of oppressed individuals and groups (L. A. Goodman, Wilson, Helms, Greenstein, & Medzhitova, 2018; L. Smith & Lau, 2013; Swartz, Limberg, & Gold, 2018). Also important is the creation of a program-wide safe space to foster frequent conversations regarding biases, microaggressions, positionality, benefits accrued from dominant statuses, and responsibilities to use privilege for community enhancement (in a culturally humble fashion), both at the individual and program levels (Davis et al., 2016; D. J. Goodman, 2011). Finally, service provided to the community in a collaborative fashion by both students and faculty has been shown to help build cultural responsiveness and advocacy skills (L. A. Goodman et al., 2018; Midgett & Doumas, 2016; Toporek & Worthington, 2014). The desired effect of the examples shared above is not only to increase cultural and social justice competence of individuals, but also to build a culturally responsive learning community in which reasons for mistrust are diminished, experiences of trust increase, and accessing beneficial mentoring can flourish.

Limitations

Despite efforts to conduct a rigorous study, the research team acknowledges our limitations within this phenomenological study. Researcher bias had the potential to influence our study at several stages. In an attempt to ameliorate bias, we followed several practices associated with enhancing trustworthiness such as keeping a reflective journal, using consensus coding, member checking, providing thick descriptions, and having an external auditor.

Social desirability was a potential limitation, as participants’ answers to questions could have been influenced by what they felt would be more acceptable in either Black academic circles or the counseling profession. To address this, the primary researcher withheld probing questions when participants told narratives that were emotionally powerful and salient. That some of the participants informally knew the primary researcher (e.g., from conversations at professional conferences) might also have influenced what was shared.

Future Research

This study highlights several possibilities for further research on trust within the counseling profession. As noted, the counseling literature lacks empirical studies on trust, despite its importance for both the supervisory and therapeutic relationship. There is a dearth of instruments measuring interpersonal trust in counseling. Creating such an instrument may be beneficial for a profession that is essentially relational.

Further inquiries into cross-racial mentoring may prove beneficial for our understanding of its benefits and perils, such as the effects of cross-racial mentoring on the racial identity development of both the mentee and the mentor. Future studies might also examine the perspectives of the White mentors involved in cross-racial relationships with students or supervisees. In addition, researchers could examine cross-racial mentoring relationships in which the mentor is Black and the mentee is White, examining the benefits and challenges experienced in these dyads. Investigations of interpersonal trust between dyads or groups comprised of marginalized and privileged people will be beneficial to the profession and those we serve. Finally, research is needed on the boundaries within the counseling profession. Most of the participants of this study believed that their relationship with their mentor needed to be more informal and less rigid (see Alvarez et al., 2009; Luedke, 2017). It may be beneficial to examine how much of one’s perspective of professional boundaries is culturally conditioned.

Summary and Conclusion

In our study, 10 Black doctoral counseling students shared a range of experiences related to cross-racial trust with White mentors, along with their perspectives about succeeding in a profession that is predominately White. Their lived experiences entailed both racial stress and cross-racial support, cultural isolation within their departments, and empathic encouragement from their mentors. The research team identified three superordinate themes related to cross-racial trust in mentoring relationships: reasons for trust, reasons for mistrust, and benefits of cross-racial mentoring. We also identified several themes and subthemes that delineated the interpersonal and intrapersonal factors that helped generate cross-racial trust, despite participants’ ubiquitous experiences of racism.

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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U.S. Army Soldiers’ Trust and Confidence in Mental Health Professionals

Sep 28, 2018 | Volume 8 - Issue 3

Anthony Hartman, Hope Schuermann, Jovanna Kenney

Despite efforts to boost mental health treatment-seeking behaviors by combat veterans, rates have improved relatively little since 2004. Previous work suggests that trust and confidence in the mental health community may be a significant factor. This study explored how professional titles may impact trust and confidence among active-duty U.S. Army soldiers (n = 32). Consistent with previous research, eight vignettes were used to solicit ordinal (ranked) trust and confidence scores for mental health professionals. Highest confidence and trust were seen in clinical psychologists and licensed professional counselors, followed by psychiatrists, licensed clinical social workers, and marriage and family therapists; however, deviations were seen for each individual vignette and the manifested symptoms depicted. Scores for trust and confidence were strongly correlated and both appear to impact soldiers’ treatment-seeking decisions.

Keywords: soldiers, mental health professionals, licensed professional counselors, trust, confidence

The U.S. Army Medical Command’s Department of Behavioral Health provides the following vision: “Our efforts in education, prevention, and early treatment are unprecedented. Our goal is to ensure that every deployed and returning soldier receives the health care they need” (U.S. Army Medical Department, 2016). In 2004, a landmark study by Hoge and colleagues found that only 13–27% of soldiers meeting screening criteria for mental health disorders sought treatment from a mental health professional in the previous year. The researchers concluded that the primary reason for such underutilization was perhaps “concern about how a soldier will be perceived by peers and by the leadership” (Hoge et al., 2004, p. 20). Subsequently, the Army has taken significant actions to reduce negative perceptions toward mental health care and increase confidentiality for those seeking treatment.

Despite substantial efforts to reduce negative stigmas, the number of soldiers seeking mental health care seems to remain significantly low. In a population of soldiers with probable post-traumatic stress disorder (PTSD) or major depression, Schell and Marshall (2008) found that “only 30 percent had received any type of minimally adequate treatment” (p. 101). Specifically, only 18% received minimally adequate talk therapy treatment. Of a sample population of National Guard and Reserve service members reporting psychological problems, Britt et al. (2011) found that only 42% had sought treatment. Most recently, Britt, Jennings, Cheung, Pury, and Zinzow (2015) found that only 40% of soldiers who acknowledged having a mental health issue sought treatment in the last year. Although the percentages of soldiers seeking treatment seem to be improving, the current literature continues to show less than half of those in need seek even a first visit with a mental health care provider. Thus, other significant deterrents to seeking treatment remain beyond the perceptions of leadership and peers.

Research studies indicate that one possible reason for this underutilization of mental health care services could be soldiers’ lack of trust or confidence in the quality of their providers or treatments. When surveyed, one in four soldiers recently returning from deployment indicated a lack of trust in mental health care practitioners (Kim, Britt, Klocko, Riviere, & Adler, 2011). Similarly, in a different sample of soldiers and Marines screening positively for mental health disorders, 38% indicated a lack of trust in mental health providers, while one in four of the same sample indicated a belief that mental health treatments were not effective (Hoge et al., 2004). Further hinting at a lack of trust for mental health care professionals and confidence in treatment, many soldiers would prefer to address their mental health issues with family, friends, or clergy (Schell & Marshall, 2008). Recently, the statement “Marines don’t trust mental health professionals” was rated as one of the top perceptions that mark barriers to care by a sample of enlisted Marine Corps leaders (VanSickle et al., 2016, p. 1022). Ultimately, there seems to be a trend of distrust and a lack of confidence in mental health care treatments and professionals among military populations.

Mental Health Practitioners and Military Treatment

Considering that there are numerous types of mental health professionals (e.g., psychiatrists, mental health counselors), it is possible that soldiers’ perceptions and knowledge of mental health professionals may vary depending on the specific type of provider. This study aims to distinguish soldiers’ perceptions between distinct mental health professionals: psychiatrists, clinical psychologists, licensed clinical social workers (LCSWs), licensed marriage and family therapists (LMFTs), and licensed professional counselors (LPCs). Psychiatrists are distinct in that they must have earned a doctorate in medicine (i.e., MD or DO) and have the nearly exclusive privilege of prescribing pharmaceutical medications for the treatment of mental disorders. Clinical psychologists also must be educated at the doctoral level (i.e., PhD or PsyD) and maintain a licensure in order to practice, but they cannot prescribe medications in most states. LCSWs, LMFTs, and LPCs are educated at least at the master’s level by an institution accredited for their respective field, and must complete respective licensing requirements that include supervised clinical experience following degree completion.

While the educational experience and licensing protocol can easily be distinguished, the mental health professions also have evolved somewhat distinct professional identities in terms of their approaches to mental health treatment. While psychiatrists are trained in various psychotherapeutic modalities, trends indicate the majority of current and future psychiatrists plan to rely more heavily on pharmacological treatments than on talk therapies (Clemens, Plakun, Lazar, & Mellman, 2014; Zisook et al., 2011). As for clinical psychologists, a review of 50 years of literature surrounding this occupation revealed trends around specializing in one particular aspect of the field (i.e., psychotherapy, assessment, research) and one or two treatment modalities (e.g., psychodynamic therapy, cognitive-behavioral therapy), and a prevalence of cognitive therapies (Norcross & Karpiak, 2012). Generally speaking, LCSWs are likely to conduct therapy from a holistic approach that heavily considers the social impacts on a person while pursing social justice and equality agendas, such as helping underprivileged groups (Bradley, Maschi, O’Brien, Morgen, & Ward, 2012). While LMFTs are often exposed to or trained in a wide variety of therapeutic paradigms and techniques, they are likely to emphasize a collective rather than individual treatment approach, often marked by working with families and couples to identify and improve systemic or transactional issues between the members (Imber-Black, 2014). As LPCs’ professional identity continues to develop and stabilize (Mellin, Hunt, & Nichols, 2011; Reiner, Dobmeier, & Hernández, 2013), professional counselors train in a variety of treatment modalities and provide a variety of services in the mental health field, including “the diagnosis and treatment of mental and emotional disorders, including addictive disorders; psychoeducational techniques aimed at the prevention of such disorders; consultation to individuals, couples, families, groups, and organizations; and research into more effective therapeutic treatment modalities” (American Counseling Association, 2011, para. 4).

Although the average client may not know or fully understand the distinctions between mental health professionals, the literature suggests clients do exhibit some bias when selecting mental health professionals. Over the past 30 years, researchers have shown a consistent trend of professional titles or education levels impacting perceptions of mental health professionals. Warner and Bradley (1991) and Wollersheim and Walsh (1993) established that both perceptions of and confidence in mental health therapies were impacted by the title and education level of the mental health professional; generally, participants in these studies indicated a lack of confidence and knowledge about clinical psychologists and a preference for treatment from counselors. In a study examining public confidence in mental health professionals, Fall, Levitov, Jennings, and Eberts (2000) found significant differences in confidence based upon their title as well as their education level (i.e., master’s vs. doctoral level); participants mostly favored doctoral-level education and preferred counselors, except when presented with “serious psychiatric disorders” (p. 122). This study was repeated in 2005 with an African American sample that provided similar findings (Fall, Levitov, Anderson, & Clay, 2005). While specific attitudes and perceptions may have changed or evolved over the past three decades, these studies show that distinct perceptions or even biases toward professional titles do exist among civilian populations. This led the researchers to question if similar trends exist in military populations, which may be influencing the treatment-seeking decisions of service members.

To summarize, soldiers’ confidence in treatment for and trust in mental health professionals might be significantly impacting treatment-seeking decisions. In multiple studies, service members have repeatedly indicated relatively low levels of trust and confidence in mental health providers and treatments. Also, researchers have consistently shown that a professional title can impact patient or public perceptions with respect to general confidence in the professional’s abilities. To date, no known research is published on military members’ perceptions and levels of confidence or trust with differing mental health professionals. Thus, the purpose of this study was to explore soldiers’ relative levels of trust for and confidence in mental health professionals based solely upon their title and a presenting issue, in an effort to better understand what may be influencing treatment-seeking decisions among U.S. Army soldiers.

Method

The researchers for this study received approval from the Institutional Review Board of their university, and the survey was approved for distribution to active-duty soldiers by Army public affairs representatives. Sample size was determined by following similar confidence in mental health professional studies that used Friedman non-parametric tests (e.g., Fall et al., 2000; Fall et al., 2005). Participants were surveyed via the online metrics program Qualtrics, ensuring anonymity.

Participants

Active-duty soldiers serving in the U.S. Army were recruited using snowball sampling initiated by public affairs representatives at various Army installations. Each potential participant received a generalized email invitation that included an information sheet about the research and a link to complete an online survey. Participants were encouraged to forward the invitation to others who also met the inclusion criteria, which limited participation to those currently serving on active duty in the U.S. Army with more than 2 years of active-duty service or the National Guard/Army Reserve equivalent. Upon completion of the survey, participants were offered the opportunity to enroll in a raffle drawing to win one of two prizes: a $100 or a $50 gift card.

The sample included 32 active-duty soldiers, 26 males and six females, between the ages of 25 and 50 years (M = 33.3, SD = 7.0). Ethnic identities included 25 non-Hispanic Whites, two Hispanic or Latinos, one African American, one Filipino, one Native American, one White/Korean, and one White/Hispanic. Most of the participants (26) were married, while three were divorced and three had never married. Nearly two-thirds of the sample indicated current responsibility for children in their homes; there was an average of 1.85 children (SD = 1.5) reported by these 20 participants. Thirteen of the soldiers had seen at least one mental health professional (MHP) prior to completing the survey; respondents had seen all five MHPs included in this study. Participants were allowed to list multiple MHPs if applicable, and the MHPs were identified as follows: clinical psychologist, seven times; psychiatrist, five times; LPC, four times; LCSW, three times; LMFT, three times; and “other” or “unsure,”five times.

Regarding military experience, the sample included 18 officers, 11 non-commissioned officers, and three junior-enlisted (i.e., rank of E1–E4) soldiers. Twenty participants had a military occupational specialty (MOS) considered as Combat Arms in the U.S. Army. In the military, not all service members are equally likely to fight in combat; certain MOSs are combat-related while others are supportive in nature (e.g., administrative personnel, mechanics, logisticians). Of our 32 qualifying participants, we had a good mix of combat and non-combat MOSs. To the reader, this may seem to be either irrelevant or not particularly noteworthy information; however, this data can be quite important when forming conclusions about the study. On average, military service was 11.4 years (SD = 7.2), with 17 months (SD = 11.5) deployed to either Iraq or Afghanistan; only two participants had not been deployed to these countries. Seventy-five percent of the sample reported direct exposure to combat, and 59% reported having never seen an MHP for even one visit throughout their life.

Materials
Demographic questionnaire. In order to provide some description of the sample population, a demographics survey of 15 questions regarding age, sex, ethnicity, marital background, parental status, military rank, deployment and combat experience, and previous experience with mental health care providers was collected from participants. Most questions were multiple-choice but offered the options to not respond or provide a unique response if desired. The remaining questions were free-response.

Vignettes. Brief vignettes were used to depict the selected mental health diagnoses or mental health issues of eight fictional soldiers recently returning from a combat deployment. The vignettes were limited in length to approximately half of a standard printed page and were written with the goal of depicting diagnostic criteria in a manner that one might see them manifested by the soldier in the vignette. Authors specifically avoided using the exact clinical terms that an MHP may use while ensuring that enough diagnostic criteria were included to suggest the intended diagnoses may be warranted.

Each vignette was followed immediately by two questions. These questions asked the participant to rank the five MHPs in order according to the participant’s preference for (1) confidence in the MHPs in providing treatment for the soldier in the vignette, and (2) their own personal trust for the professionals if they were experiencing the symptoms described in the vignette. Because both questions were worded similarly, keywords such as trust and confident were bolded or underlined in order to highlight the intent of the question.

Development and validation of the vignettes.
The vignettes and questions were originally drafted by the lead researcher to explore how soldiers may rank MHPs under the two stated conditions (i.e., confidence and trust questions). The four mental health diagnoses selected were PTSD, anxiety disorders, depression, and substance use disorders, as these were identified by Seal, Bertenthal, Miner, Sen, and Marmar (2007) to be the most prevalent for soldiers returning from Iraq. The four common issues were suicide, marital problems, parenting difficulties, and sleep problems; these were selected from the Military Health System’s “After Deployment” (2015) website because they were depicted as common problems faced by soldiers and contributed to the breadth of issues explored in the study. Vignettes were modeled after previous studies using similar metrics to measure populations’ trust of MHPs (e.g., Fall et al., 2000; Fall et al., 2005).

After review and editing within the research team, faculty with extensive clinical and teaching expertise in the area of diagnosis reviewed the vignettes. Based on their recommendations, specific diagnostic labels, such as PTSD and depression, were removed in order to reduce the impact of these labels on participants’ responses, and the keywords trust and confidence were included and bolded in the survey questions. Their input also resulted in the refining of the vignettes to more accurately depict the intended issues based upon their clinical experience and expertise.

Procedures
From January to June of 2017, surveys were administered via Qualtrics software on an electronic device of the participant’s choosing. Respondents were requested to complete the surveys at a location and time presenting minimal distractions. After being provided information about the study and consenting to continue, participants were presented with the demographics survey followed by the vignettes. The survey would not advance to the next page unless a response was recorded to all questions on the previous page. Upon completion of the demographics portion, participants advanced to the vignettes depicting soldiers facing issues upon returning from a combat deployment.

During the vignette portion of the survey, respondents ranked the list of mental health practitioners for both the confidence and trust conditions; see the Appendix for the vignettes presented to participants. The survey would not allow duplicate ranks (i.e., MHPs could not “tie”) for either condition. The vignettes were randomized, with both the trust and confidence questions presented together on the same screen, and the listed order of the MHPs was randomized for each vignette as well.

Analysis
Data analysis focused on three main themes: the mean ranks for trust of the MHPs across the vignettes, the mean ranks for confidence in the MHPs across the vignettes, and potential correlation between trust and confidence. Consistent with the Fall et al. (2005) analysis, Friedman non-parametric tests and Wilcoxon matched-pairs tests were used to determine significant findings in the mean ranks for MHPs in each vignette with respect to both the confidence and trust conditions separately. These tests were completed 16 times—once for each of the eight vignettes for both the trust and confidence questions. Afterward, the data was aggregated separately for both the trust and confidence questions to allow an overall assessment of the mean ranks for each MHP without concern for the particular vignette presented. Both the Friedman and Wilcoxon tests were completed again on the aggregated data. Finally, a Goodman and Kruskall’s gamma test was used to determine the correlation between trust and confidence ranking for each MHP.

Results

For all eight vignettes, significant differences (n = 32, df = 4, p <= .002) were found for mean rankings in both confidence and trust conditions. Subsequently, Wilcoxon matched-pairs tests identified statistically significant differences within groups for each of the 16 conditions; see Table 1 for specific results. Figures 1 and 2 display inverted mean rankings for each MHP by vignette for the confidence and trust questions respectively; higher scores indicate a more favorable ranking.

In both the confidence and trust conditions, the data from each vignette allowed for the separation of the five MHPs into either two or three distinct groups in terms of their rankings. In some instances, some MHPs could be grouped with both the higher- and lower-ranking adjacent MHP; in this case, the MHP was placed in both groups. For example, in Table 1 under the Aggregate Rank column for the confidence condition, there was no significant difference between LPCs and psychiatrists (N = 256, p = .202), or LPCs and psychologists (N = 256, p = .336), but there was a significant difference between psychologists and psychiatrists (N = 256, p = .011).

Lastly, scores from all eight vignettes were aggregated for each MHP to allow an overall measure of the MHP’s ranking for both confidence and trust. Table 1 includes the associated statistically significant grouping, and Figure 3 depicts the aggregated inverted mean ranking for both conditions for each MHP. Using a Goodman and Kruskall’s gamma test on the aggregated data, a strong positive correlation was found between confidence and trust ratings for all five MHPs with G values ranging from 0.72 to 0.88 (N = 256, p < .0005).

Figure 1. Inverted Mean Ranks for Confidence Question Plotted by Type of Mental Health Professional and Vignette. Higher mean rank equates to higher confidence.

Figure 2. Inverted Mean Ranks for Trust Question Plotted by Type of Mental Health Professional and Vignette. Higher mean rank equates to higher trust.

Figure 3. Aggregated Inverted Mean Ranks for Mental Health Professionals for Confidence and Trust Questions. Higher mean rank equates to higher confidence or trust. Error bars indicate standard error based on standard deviation from the mean; they do not indicate statistical significance.

Discussion

This study was designed to explore active-duty Army soldiers’ perceptions toward various mental health care providers with respect to trust and confidence in the MHP. Overall, the sample population of soldiers appears to have the highest confidence and trust in clinical psychologists and LPCs, while LCSWs and LMFTs are significantly less preferred (as seen in Table 1). Psychiatrists seem to be somewhere between each of these two groups, as they appear in both the highest and second-highest preferred groups depending on the condition (i.e., confidence or trust). The statistically significant stratification into these groups suggests that the title of available MHPs may influence a soldier’s decision to seek services. Undoubtedly, other factors are involved, but the title, and perhaps the certifications of the available professional, is likely impacting treatment-seeking behaviors in military communities.

At the heart of this study is the notion that each of the MHPs included could treat any of the soldiers in the vignettes; however, the results suggest that soldiers would seek out different professionals based on the context of the presenting symptoms rather than the type or potential efficacy of the treatment to be received. For example, the marital problems vignette (see Appendix) could arguably have been treated more effectively by a psychiatrist than an LMFT; perhaps the declining relationship was itself a symptom of biochemical issues such as vitamin or neurotransmitter deficiencies, which may be more aptly treated with medicine. Or, it also is possible that an experienced LPC or LCSW could have effectively brought to the surface some other underlying issue in the course of individual therapy rather than the marriage, couple, and family-oriented approach taken by an LMFT. Similar arguments could be made for each of the other vignettes, but the results suggest that soldiers are likely making treatment decisions based upon professional title and presumably the associated reputation. If the Army’s goal is to boost rates of treatment-seeking behaviors, professional titles and perceptions of trust and confidence should not be ignored.

Results also show a strong correlation between trust and confidence across all of the vignettes. This can best be seen by comparing the LMFTs’ rankings for the marital problems and parenting issues vignettes with their consistently lower scores on the other vignettes. The jump in scores was consistent across both conditions, demonstrating that trust and confidence for MHPs are strongly linked. Although less likely, it also is possible that the respondents might have been biased or influenced to provide similar ranks for each professional across both conditions because the survey design allowed them to see their scores for the confidence question while completing the trust question. Regardless of whether trust influences confidence or vice versa, the two should be considered in the quest to boost treatment-seeking rates among soldiers.

Implications for Service Provision
With further validating and corroborating research, the Army may be able to improve treatment-seeking rates among those in need of mental health care by adjusting services based on the perceptions of soldiers. Although LPCs were consistently favored more than LCSWs, the Army currently allows LCSWs to serve as commissioned officers in behavioral health clinics providing individual therapy to soldiers, while the LPC license does not qualify an MHP to commission and serve as an officer (U.S. Department of the Army, 2007). This means soldiers have fewer chances of seeing an LPC without some type of insurance referral because the uniformed personnel initially available will not be LPCs. This study provides evidence that LPCs may be more appropriate and effective in this role by boosting treatment-seeking rates, so it could be beneficial to make treatment with LPCs more accessible to soldiers. Likewise, incorporating the services of LMFTs following deployments could help military families, as they had the highest average trust and confidence ratings of any professional in any vignette in the study when they were the preferred MHP. Perhaps they could advocate for temporary positions following deployments or increased advertisement of their services in military communities with units returning from overseas.

Limitations and Future Research
Future research is certainly needed to further confirm the results of this study. Investigators could explore what drives trust and confidence perceptions in military communities and how prior personal experiences influence the soldiers’ views of MHPs. Studies like this one could be conducted with other branches of the military and include National Guard and Reserve forces. Exploratory qualitative research could seek to identify specific factors that build trust and confidence in the mental health community as a whole. Future studies also should continue to update the disorders or issues selected to accurately represent the issues faced by targeted populations at the time.

Limitations to this study include the sample size, delivery of the survey, and lack of consideration for gender biases. While 32 respondents can provide initial insights, a much larger sample should be surveyed before any significant policy decisions are considered. The research team also recommends administering the surveys in person rather than online with the belief that many soldiers—and people in general—may not complete the digital surveys as earnestly as a paper version following a personal interaction with the research team or a recruiter. With regards to gender, it was not considered how the names of the soldiers in the vignettes may influence the respondents’ rankings; it is possible that the scores could have varied if the soldier in the vignette was of a specific gender.

Future researchers should be cautious to ensure that voluntary participation is not influenced by environmental pressures. In military communities, the researchers recommend seeking a sample population that includes personnel from multiple units, locations, and MOSs, as culture and attitudes can be vastly different among these variables.

Although this study has limitations, the researchers believe it highlights one of the key reasons that soldiers may not seek mental health services when in need: lack of trust and confidence in the resources available. Although the military has significantly addressed other identified issues, such as the associated stigma or impact to a service member’s career, treatment-seeking rates for those in need have changed very little, which indicates other issues are contributing to the decision not to visit with an MHP. The researchers hope the results of this study are built upon and examined for alternative approaches to boost treatment-seeking rates among the military.

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

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Appendix

Vignettes Used to Depict Mental Health Diagnoses and Issues

Post-Traumatic Stress Disorder Vignette
Joe returned from deployment to Afghanistan 4 months ago. He was personally involved in combat with enemy insurgents on multiple occasions and was exposed to disfigured, dead bodies of both enemy combatants and fellow soldiers as well. He has often mentioned bad dreams about one of these times in particular and seems obviously distressed (e.g., fidgeting, faster breathing, and sometimes even sweating) whenever he speaks about it. However, when his fellow soldiers from the deployment bring up the event, he seems unwilling to participate in the conversation and has on a few occasions become angry about it. Based on these behaviors, you believe he may be struggling with traumatic experiences.

Anxiety Disorder Vignette
John returned from a combat deployment 9 months ago. Since returning, his family and coworkers have noticed changes in his behavior. He is often restless (or “on edge”), irritable, or physically tense in common, everyday situations. Plus, he has claimed poor or unsatisfying sleep for several months. These symptoms seem to be impairing his work performance and damaging personal relationships with loved ones. When asked, he hasn’t mentioned any particular traumatic events or worries that are bothering him. He simply seems much more anxious and it is affecting his well-being.

Depression Vignette
Jane returned from a combat deployment 3 months ago and has generally seemed a little bit down since coming home. Nearly every day over the past 2 weeks she has seemed to be sad or gloomy throughout the day and has shown very little interest in doing things she used to enjoy. She is clearly tired throughout the day and has mentioned feeling worthless to those around her. It seems like she is suffering greatly based on her unhappy and sad moods.

Substance Abuse Disorder Vignette
Jim returned from a combat deployment 12 months ago. Upon returning, he seemed to seamlessly reintegrate with his family, friends, and former social life. However, he soon began drinking alcohol more heavily than ever before, often binge drinking until passing out on weekdays and weekends. Although never caught in the act, he has even gone to work intoxicated and driven while drunk on multiple occasions. On two distinct occasions, he attempted to reduce his alcohol consumption but failed after only a week or two. Alcohol abuse is beginning to disrupt his work performance, family life, and physical well-being.

Sleep Problems Vignette
Joan returned from a combat deployment 4 months ago. She seems to have reintegrated very successfully into her family, social, and work environments. However, her sleep patterns have become very irregular and unsatisfactory. She rarely gets more than 4 hours of sleep consecutively and often uses her weekends to recover from a week of sleepless nights. Although her family and coworkers haven’t noticed anything wrong, Joan fears her sleep problems will soon begin disrupting her life.

Suicide Risk Vignette
James returned from a combat deployment 6 months ago. Since returning, he has outwardly seemed to have successfully reintegrated into his family, work, and social life. Although he appears to have been changed by his combat experiences, he does not seem to be generally troubled in any way (e.g., depressed, anxious, abusing drugs). However, he has jokingly mentioned “blowing his brains out” to colleagues at work and mentioned a specific plan to take his own life with his pistol. During a conversation with two friends, he has mentioned “ending it all” because he is feeling hopeless. You think James may be at risk for suicide.

Marital Problems Vignette
Jon returned from a combat deployment 5 months ago. He has rejoined his wife of 6 years, but their relationship has changed. While they used to feel very close and connected, they now both feel very distant. They do not enjoy activities together which they used to, such as hiking and dancing. They rarely hold good conversations with each other and are also less physically intimate. Jon and his wife both want their marriage to work but fear that they are nearing divorce. They are facing the most significant period of marital problems they have ever experienced.

Parenting Issues Vignette
Jerry returned from a combat deployment 10 months ago. He rejoined his wife of 16 years, their 13-year-old daughter, and their 5-year-old son. Since returning, Jerry has experienced some difficulty reassuming his role as a parent. His daughter seems to want very little to do with him. Although he thinks this is typical of a 13-year-old, it still causes him distress and he complains that he doesn’t feel like he has any influence in her life. With their son, Jerry often disagrees with his wife on discipline issues, and he can’t seem to find ways to connect with the 5-year-old. His son seems to have little interest in playing anything besides video games and always runs to his mother when Jerry attempts to discipline him. These parenting issues are significantly affecting Jerry’s mental and emotional well-being.

Anthony Hartman is a medical student at UT-Health San Antonio. Hope Schuermann is a clinical assistant professor at the University of Florida. Jovanna Kenney is a therapist at Genesis Psychiatric Center in San Antonio, TX. Correspondence can be addressed to Anthony Hartman, 7703 Floyd Curl Drive, San Antonio, TX 78229, hartmanaj@livemail.uthscsa.edu.

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