Providing Wellness Counseling in Older Adult Living Communities: Challenges and Opportunities

Matthew C. Fullen, Jonathan D. Wiley, Paul M. Delaughter, Connie C. Tomlin, Jordan B. Westcott, Nick Gowen

Older adult living communities (OALCs; i.e., continuing care retirement communities, assisted living facilities, and long-term care settings) are growing in number and complexity, and industry leaders are recognizing that promoting wellness among their residents is a top priority. Although OALCs offer services to keep their residents engaged and active, residents’ emotional needs often go unmet. Adults who reside in OALCs are likely to benefit from counseling services, especially when delivered within a wellness framework; however, there is inconsistent availability of wellness counseling within OALCs. Our article describes how wellness approaches can be utilized, addresses the unique counseling needs of OALC residents, and considers the importance of multicultural competence when serving older adults. The included case study highlights the promise of wellness counseling in OALCs.

Keywords: older adults, counseling, wellness, living communities, assisted living

 

Older adult living communities (OALCs) play an essential role in promoting multidimensional wellness among older adults (Hettler, 1976). OALCs are growing in number and complexity, and industry leaders suggest that promoting wellness among residents is a top priority (Johnson, 2025). Although OALCs offer services that engage residents’ multidimensional wellness, their mental health needs often go unmet (Fullen, Wiley, et al., 2020). Adults who reside in these communities are likely to benefit from counseling services; however, counseling is not consistently available within OALCs (Fullen, Wiley, et al., 2020).

Concurrent with the population increases of older adults, the number of OALCs, such as continuing care retirement communities, assisted living facilities, and long-term care settings, is increasing across the United States (Christman, 2025). According to the U.S. Census Bureau, by 2060 almost a quarter of all U.S. residents will be over age 65 and life expectancy will reach 85 years (Medina et al., 2020). It is estimated that OALCs will need to hire 1.2 million new employees across professional domains in order to meet residents’ needs and account for this growth in the older adult population (Argentum, 2016).

Demographic and industry trends point to counselors being well-positioned to meet the mental health and emotional wellness needs within OALCs. This is a timely development in the counseling profession, as licensed counselors recently became eligible to enroll as Medicare-eligible providers (Consolidated Appropriations Act, 2023). However, counselors face the challenges of understanding the counseling needs of older adults, practicing culturally competent care, and overcoming the obstacles related to providing professional counseling services within OALCs (Fullen, Wiley, et al., 2020). Therefore, we describe the unique counseling needs of residents of OALCs, as well as specific challenges to providing counseling services within OALCs related to mental health services integration, payment and reimbursement, and counselor education, training, and supervision. Because OALCs are increasingly using a wellness framework in their approaches to older adult health care, we will also describe how wellness can be used to introduce counseling within these settings.

Older Adult Wellness Counseling
     To better conceptualize older adult wellness, it is helpful to summarize the eight dimensions of older adult wellness that have been described in our previous work (Fullen, 2019). These dimensions include physical, relational, emotional, developmental, spiritual, cognitive, contextual, and vocational domains. These dimensions are briefly defined in Table 1, with a corresponding assessment question included for reference.

Table 1

Eight Dimensions of Wellness in Older Adulthood

Wellness Dimension Brief Definition (derived from Fullen, 2019) Sample Assessment Question
Physical Taking care of one’s body, as well as attending to needs associated with disability, chronic illness, or pain In what ways do you continue to care for your body?
Relational Maintaining meaningful relationships with friends, family, and others in your community Do you feel supported by those around you, and how do you support others?
Emotional Maintaining hope and resilience in spite of challenges one faces Are you content, and do you think you will be in the future?
Developmental The need to develop healthy, realistic attitudes about growing older What does growing older mean to you?
Spiritual Exploring your meaning and purpose Where do you find meaning in your daily life?
Cognitive Fostering control, self-efficacy, and commitment to brain health and lifelong learning How do you exercise your brain?
Contextual Inhabiting a community where you belong and thrive Do you feel secure and supported where you live?
Vocational Pursuing your life’s calling, regardless of whether the calling is associated with paid work What is your calling?

 

Wellness Counseling
     Multidimensional wellness is based on the assumption that older adults have holistic needs that may reflect intersections between physical, emotional, social, or spiritual domains (Fullen, 2019). Wellness counseling occurs when counselors incorporate multidimensional assessment and treatment planning, a focus on client strengths, and a paradigm shift from addressing illness to promoting growth and self-discovery (Fullen, 2016). Frameworks for wellness counseling across client ages have been described (Ohrt et al., 2019), and specific modifications for using wellness counseling with older adults exist (Fullen, 2019). Wellness counseling has been identified as a strategy to counteract ageism (Fullen, 2019), particularly because of the medicalization of aging and the shift away from illness and client deficits that is emphasized within the wellness paradigm. Because older adult wellness is multidimensional, counselors using a wellness framework may identify several wellness dimensions that correspond with particular presenting problems. Therefore, the practice of wellness counseling begins with a multidimensional assessment of a client’s wellness, followed by a review of the client’s strengths, and ongoing discussion about how to apply these strengths to meet specific, multidimensional wellness goals and challenges that older adult clients may bring to counseling. Consistent with its focus on holism, counselors using a wellness counseling approach emphasize how client strengths can be leveraged to address areas of vulnerability (Fullen, 2016). Areas of strength may be targeted for additional growth, whereas areas of present vulnerability may be highlighted for intervention. As interventions are applied, ongoing assessment of wellness dimensions occurs to advance the pursuit of holistic wellness.

Wellness Challenges Facing Older Adults in OALCs
     Older adults residing in OALCs face many of the same challenges as their peers living outside of these settings. Living in a residential setting can provide older adults with security and comfort, enabling them to age in place. Many OALCs offer a range of care options, including independent living, assisted living, skilled nursing, long-term care, and memory care (Shippee, 2012). Although these communities are designed to promote aging well in multiple dimensions (e.g., physical wellness, social wellness, intellectual wellness; Johnson, 2025), some residents will experience wellness challenges that necessitate counseling intervention (Fullen, 2016). Counselors working in these settings need to be prepared to meet residents’ counseling needs and to be aware of the unique challenges that older adults living in OALCs routinely face. When considering how to apply a wellness framework to counseling older adults in OALCs, counselors can respond by engaging clients in dialogue about how common challenges impact their wellness, identifying clients’ wellness strengths, and developing strategies to leverage strengths to address specific challenges.

Grief and Loss
     Grief and loss issues are common among older adults. In addition to grief associated with the loss of family members and friends, there are other substantial losses that older adults face, including the loss of independence, home, health and mobility, vision and hearing, career and purpose, finances, preferred living arrangements, and cognitive abilities (Gitterman & Knight, 2019). Sometimes the decision to move into an OALC is made after losing a spouse, which could include a long-term grieving process (Sopcheck, 2020). In some cases, people decide to move into OALCs shortly after retirement, anticipating a comfortable life with fewer responsibilities, appealing amenities, and the comfort provided by being surrounded by others in their same age cohort (Brecht et al., 2009). Considerations of both contextual and developmental wellness can be valuable when responding to grief and loss. For example, asking an OALC client to define what it would look like to feel secure and supported (i.e., contextual wellness) during a period of bereavement may promote their sense of belonging within the OALC, which could contribute to the belief that the next phase of life is still worthwhile (i.e., developmental wellness). Moreover, helping clients identify wellness strengths during a period of grief and loss can be beneficial. For example, an OALC client may experience encouragement at the thought that a deceased loved one would be proud of them for meeting new friends in their OALC community, which reflects a form of relational wellness.

For those moving into these communities shortly after retiring, the loss of career and vocation may result in tremendous challenges (LaBauve & Robinson, 2011). This life stage transition can result in feelings associated with a lack of purpose and belonging, and the loss of a social network that may have been in place for many years (Myers & Degges-White, 2007). Another challenging adjustment for older adults occurs when they are no longer able to drive. This decision is often prompted by other family members who encourage them to stop driving, making many older adults feel as if they have lost a key element of their independence (Bell & Menec, 2015). Supporting clients in reappraising their vocational wellness, which may involve broaching how they continue to pursue a sense of meaning and purpose in their lives, can be beneficial.

Adjustment
     In contrast, other older adults are forced to move into these settings because of failing health, mobility issues, or cognitive decline (Krout et al., 2002). Adjustment issues related to failing health can be difficult for older adults, and many live with chronic pain, limited mobility, and full reliance on others for care. Older adults who relocate to an OALC may have left behind a home of many years, familiar surroundings and routines, as well as friends and neighbors. Many older adults are surprised by the intense feelings that arise shortly after moving into a facility (Ayalon & Green, 2012), including an extended period of grief. For older adults who have lived most of their lives in single family dwellings, sharing common areas such as dining halls and activity spaces may be difficult (Chaudhury et al., 2013). These adjustments are particularly pronounced for older adults who transition to higher levels of care in OALCs. Nighttime sleep disturbances are common and may result in a variety of physical and mental health issues (Martin & Ancoli-Israel, 2008). For individuals facing physical health challenges, the dimension of physical wellness may be most relevant. Specifically, encouraging clients to consider ways in which they continue to care for their bodies, despite bodily changes they may be experiencing, can shift the emphasis from a focus on client deficits to one of resilience and strength.

Moving into an OALC is a significant life adjustment that can lead to emotional distress. In the early stages of adjustment, residents may find it difficult to refer to their OALC as their home; instead, they may hold on to emotional connections to their prior residence. They may feel ambivalent and uncertain as they struggle to place themselves within the existing categories of residents, which may reflect the disenfranchisement of their grief and grieving process (Ayalon & Green, 2012). For some, this may be the first time they have been in a setting where most people around them use assistive devices such as canes, walkers, and wheelchairs (Ayalon, 2015). Mental health concerns may rise to a level of depression and/or anxiety. Depression may result from various factors, including the adjustment to living in an OALC, profound grief and loss, failing health, and lack of purpose and belonging (Ayalon & Green, 2012). Anxiety can also be a concern for adults in these settings as they face their mortality, financial worries, fear of decline and death, and loss of independence, which would require them to rely on others for care (Creighton et al., 2016). Understanding the impact of these adjustments on emotional wellness may be an important first step in these cases.

Relationships
     One of the most challenging life transitions older adults face is the shift in family dynamics that occurs when children begin to take care of their parents (Branson et al., 2019). As older adults move into advanced levels of care in OALCs, their adult children may experience guilt for having placed their parents in a “home.” This guilt may lead to overinvolvement and overprotection by their children, which can be a source of frustration for the older adults (Davis et al., 2019). For spouses moving into OALCs together, the strain of living in a smaller environment may create tension (Ayalon & Greed, 2016). Oftentimes, one spouse may be the primary caregiver for the other, which can also create relational challenges (Polenick & DePasquale, 2019). Approaching these cases from a relational wellness perspective allows both the counselor and the client to assess changes in their relationship and how clients continue to receive and provide emotional support. The therapeutic relationship can also function as a source of relational wellness, which may provide clients with the foundation they need to pursue other relationships with OALC community members, friends outside the OALC, or family members.

Alzheimer’s Disease and Other Related Dementias
     As the size and proportion of the U.S. population aged 65 and older continue to increase, the number of Americans with Alzheimer’s and other related dementias will continue to rise. There are currently an estimated 7.4 million Americans living with Alzheimer’s dementia (Alzheimer’s Association, 2026). Those in the earlier stages of the disease are often undiagnosed and still capable of living independently (Savva & Arthur, 2015). Older adults residing in OALCs during this phase of the disease may withdraw from social activities because of feelings of inadequacy associated with their cognitive impairment (Nelis et al., 2011). Others may not recognize the changes they are experiencing, which can lead to confusion, frustration, and embarrassment in social situations (Robinson et al., 2012). Maximizing the length of independence for those with early-stage dementia is critical because it is likely their last phase of life for living independently. Quality of life is likely to be significantly reduced as the disease progresses. Counselors can play a vital role for these individuals by maximizing the length of time they can live independently. Although counseling can be instrumental for people in all stages of dementia, OALC residents with early-stage dementia may find counseling services particularly beneficial.

Given the complexity of Alzheimer’s Disease and other related dementias, a multifaceted approach to older adult wellness could be useful (Fullen, 2019). By using the eight dimensions of wellness, a counselor may find specific strengths or shortcomings in areas such as relational wellness, cognitive wellness, emotional wellness, or contextual wellness. Clients who are caregivers may have needs in the same dimensions, as well as in areas such as vocational wellness, developmental wellness, and spiritual wellness. Identifying wellness dimensions in which clients and caregivers maintain strengths may be a helpful strategy in maintaining quality of life and bolstering a sense of resolve during what can be an overwhelming and discouraging experience.

Substance Misuse
     As the Boomer generation (i.e., adults born between 1946 and 1964) continues to enter older adulthood, a growing number of older adults are at risk for alcohol and substance abuse (Barry & Blow, 2016). Misuse of alcohol and prescription drugs among older adults is currently higher than in previous generations, partially attributed to the 25% of older adults who are prescribed potentially addictive psychoactive medications, which are the most prevalent medications prescribed to this age group (Ogbonna & Lembke, 2019). Older adults residing in OALCs typically have convenient and frequent access to alcohol at planned social gatherings. Researchers assert that alcohol may be used as a coping mechanism for those living in these settings (Sacco et al., 2015). There may be less concern about limiting social drinking, as driving is less common. However, there are numerous negative consequences for older adults, including increased fall risks and harmful drug interactions (Barry & Blow, 2016). Many older adults are unaware of substance abuse ramifications, particularly related to the physiological changes related to aging that make them more vulnerable to these adverse effects (Williams et al., 2005).

Counselors can play a supportive role for these older adults through both psychoeducation and professional treatment. Problematic substance use has a multifaceted connection to wellness, requiring counselors to consider an array of relevant wellness dimensions, such as physical wellness, emotional wellness, and relational wellness. Once one or more areas of wellness are identified for greater emphasis during treatment, it is also important to discuss which areas of wellness continue to be sources of strength. For example, an OALC resident whose alcohol use has negatively impacted their relationships may describe how taking care of their body through walking or lifting weights (physical wellness) continues to provide a healthy sense of control and self-efficacy (cognitive wellness).

Ageism
     Counseling professionals in OALCs should be knowledgeable about experiences associated with aging, including societal stigma against older adults. Ageism, or prejudice, stereotyping, and discrimination against older adults based on age (Butler, 1969), negatively influences older adults’ mental health (Gendron et al., 2016). Like other forms of prejudice, ageism is systemic (Fullen, 2018).
For example, stereotypes about older adults permeate American culture and can lead to poor mental health outcomes for older adults (Fullen, 2018). Systemic ageism is reinforced by individual, interpersonal expressions of ageism, which older adults may experience from medical professionals, family members, and even OALC staff.

Furthermore, older adults may assimilate negative stereotypes about aging and late life into their self-concept, leading to internalized ageism, through which they may believe negative stereotypes about themselves or discriminate against other older adults (Gendron et al., 2016). Counselors working in these settings should be aware of the impact that ageism can have on older adults and remain vigilant in identifying ways in which ageism is organizationally embedded in OALCs. Attitudes toward aging contribute to a person’s developmental wellness, which can be more broadly assessed through therapeutic dialogue (Fullen, 2019). When clients describe internalized aging attitudes, it is important to identify the origin of these messages. Gently challenging these ageist assumptions can enhance the therapeutic relationship (relational wellness) and result in a greater sense of resilience (emotional wellness) and self-efficacy (cognitive wellness).

Culturally Responsive Care With Older Adults in OALCs
     In addition to being prepared to work with a wide variety of clinical concerns using a wellness framework, counselors working in OALCs should be prepared to work with clients from many different backgrounds with diverse lived experiences. It is important to ask clients how their sociocultural experiences, as well as gender, socioeconomic status, and religious affiliations, influence how they define the eight dimensions of wellness for themselves. Counselors can best meet their clients’ needs when they understand clients contextually, considering the unique experiences that have informed clients’ lives based on their sociocultural identities (Ratts et al., 2016). Although all clients have specific cultural considerations counselors should attend to, counselors who desire to work in OALCs must be aware of specific issues in later life and how sociocultural factors can influence development across the lifespan (Fullen, 2020b).

Use an Intersectional Lens
     Counselors who practice in OALCs will undoubtedly work with clients who have been impacted by ageism. However, many clients will hold additional marginalized identities that influence their experiences of aging and ageism. The intersection of age with other marginalized identities significantly alters the experiences of aging for older adults (Wang et al., 2025). Crenshaw (1989) introduced the construct of intersectionality to explain how occupying two or more marginalized positionalities creates a gestalt experience of discrimination. Intersectionality is a framework that enables people to understand how interlocking systems of oppression can exacerbate one another, creating a unique experience for individuals who hold multiple minoritized identities (Crenshaw, 1989). In essence, understanding clients in OALCs through an intersectional lens is crucial for developing a nuanced understanding of their experiences and clinical concerns. Therefore, in addition to the necessity of understanding systemic ageism (Fullen, 2018), counselors who provide services in the context of OALCs should be aware of the unique intersections other sociocultural factors can have with age in such settings.

Social determinants of health, such as race/ethnicity, gender/gender identity, sexual orientation, and socioeconomic status, influence clients’ mental health across the lifespan, with some effects emerging in later life (Allen et al., 2014). Additionally, there is evidence that inequity across the lifespan leads to poorer mental health outcomes in older adulthood for marginalized groups, such as racial/ethnic minority older adults (Ferraro et al., 2017); lesbian, gay, bisexual, and transgender (LGBTQ+) older adults (Fredriksen-Goldsen et al., 2017); and older adults with disabilities (Kattari et al., 2017). These findings suggest that the older adults who are most likely to need counseling are also more likely to have experienced unique intersectional challenges. Therefore, understanding clients’ contexts and backgrounds, selecting appropriate interventions and assessments that account for clients’ unique cultural considerations, and providing opportunities for clients to process experiences of discrimination and stigma are all critical components of culturally competent care for all clients.

Broach Culture
     Counselors should endeavor to learn about their clients’ cultures, broach cultural differences, select culturally appropriate interventions and assessments, and engage in advocacy within OALCs to ensure equitable access to resources and programming (Day-Vines et al., 2007; Ratts et al., 2016). To understand the salience of client identities and how these identities have influenced the client’s life, it is crucial to directly discuss both the client’s culture and the cultural differences between the counselor and the client early in the counseling process (Day-Vines et al., 2007). Broaching the client’s culture provides them with the opportunity to share their most salient identities, how those identities have shaped their lives, and how those identities influence their experience in their OALC. This strategy also provides an opportunity for the counselor to demonstrate cultural humility and indicate that they will not perpetuate the same harm that clients may experience from staff or other residents in the community.

Similarly, counselors must commit to learning about their clients’ cultures, including the influence of age and generational cohort (Ratts et al., 2016). For example, counselors who work in OALCs should familiarize themselves with adult development and aging rather than educating themselves on the basics related to that process. By developing a knowledge base around the aging process, counselors create space for their clients to share their unique experiences of aging. In order to conceptualize their clients through an intersectional framework, counselors should also research how aging is perceived in the various cultures their clients belong to (Ratts et al., 2016). This approach may require the counselor to develop self-awareness concerning implicit biases they may possess regarding their clients’ cultural identities to ensure that they do not contribute to their clients’ experience of marginalization. Particularly salient is ageism, which counselors may invoke in counseling if they do not develop awareness around their biases related to the aging process (Fullen, 2018). In learning about their clients’ cultures, counselors have the opportunity to select interventions and assessments that are culturally appropriate based on age and other sociocultural factors that impact the client.

Address Systemic Barriers
     Finally, inequitable access to resources impacts older adults who reside in OALCs. Counselors should advocate within their workplace to address systemic barriers to access within the community (Ratts et al., 2016), help specific clients access necessary resources (Ratts et al., 2016), and develop programming that meets the unique needs of residents who are disproportionately impacted. Ultimately, counselors must attend to their clients’ holistic cultural experiences and maintain an awareness of the risks posed to older adults by a lifetime of marginalization. An essential consideration for culturally responsive work with older adults is selecting appropriate theory and empirically sound interventions.

Case Study
     Michelle, a licensed counselor, begins a new staff position at a local continuing care retirement community, where she will provide talk therapy services to residents. This is the retirement community’s first counselor, and Michelle understands that this may be some of the residents’ first experience with a mental health professional. To broach the topic of mental health at a services fair hosted by the community, Michelle creates a booth and designs a flyer outlining the eight dimensions of wellness and describing how they relate to older adult mental health. Residents stop by Michelle’s booth at the services fair, and she uses the tool as a conversation starter about mental health and also a preview of what working with her in individual therapy sessions may entail.

One community resident, Roy, tells Michelle that he is struck by her description of vocational wellness, particularly the question, “What is your calling?” Roy admits that he has only thought about “vocation” in terms of his career, from which he retired over a decade ago. He tells Michelle that he has been struggling with the concepts of purpose and meaning since moving to the community, and Michelle invites Roy to schedule an individual session with her to discuss these ideas in depth.

During their intake session, Michelle reminds Roy of the eight dimensions of wellness and asks him to point out any dimensions that are going particularly well in his life. She also broaches culture with Roy and invites him to share how aging is viewed among people who share his cultural background. Roy remarks that he had previously seen aging as “only going downhill” and admits that he has not thought about his wellness so much as his illness. Michelle uses this as an opportunity to take a strengths-based approach with Roy, explaining that enhancing certain aspects of wellness can help offset any inevitable or sudden deterioration in other aspects of wellness. Hearing this, Roy describes his robust social life in the retirement community—a sign of high relational wellness—and how his relationships increased his well-being, in spite of a worsening eye condition that has left him unable to see far distances (an example of decreasing physical wellness). Michelle notes how Roy’s increased relational wellness may be positively offsetting his declining physical wellness; she uses this as an example of the importance of a holistic approach to wellness in Roy’s life. Michelle and Roy decide to include vocational, physical, and relational wellness in Roy’s treatment plan. Together, they decide on three counseling treatment goals: 1) Determine what gives Roy meaning and purpose, and identify concrete actions to incorporate meaning and purpose into each day (vocational wellness); 2) Care for his eyesight as best he can while also maintaining a healthy diet and routine exercise in consultation with his primary care provider (physical wellness); and 3) Invest in existing and new friendships within his OALC with a goal of thriving in the area of relational wellness.

After the initial session, Michelle reflects on her session with Roy. She is pleased that the eight dimensions of wellness provide her with a helpful, strengths-based lens through which to view aging and older adulthood. She reflects that previously in her career, she overly focused on older adults’ physical wellness, often medicalizing the aging process and “othering” aging bodies. By exposing herself to a holistic approach to older adult mental health, Michelle challenges her own ageist beliefs and behaviors and notes that wellness can exist at any age.

Challenges Facing Counselors Working in OALCs
     Despite the numerous benefits of integrating wellness-based counseling services within OALCs (Fullen, 2020b), there are several challenges to consider. Historically, OALCs have been slower to integrate mental health services compared to medical services. Payment barriers for counseling have historically interfered with creating opportunities to work within this context. Finally, there are barriers associated with how counselor education programs prepare students, which have limited the growth of counseling within OALCs. The following section will describe each of these barriers.

Mental Health Services Integration Challenges
     Although older adults’ mental health needs are well documented (Moye et al., 2019), the number of OALCs that employ or contract with a mental health professional is unclear. In a large survey of counseling professionals, only 1.6% described 65 years of age and older as a primary area of clinical emphasis (Fullen, Lawson, & Sharma, 2020). Additionally, in a study of psychologists, scholars found that only 1.2% described geropsychology as a specialty area (Moye et al., 2019). Moye and colleagues found that psychologists who specialize in working with older adults were more likely to work in independent practice, including over half of private practice practitioners. However, it is not clear how often their services were integrated into OALCs.

The presence of counseling services within long-term care settings is slightly more apparent. A survey of Florida nursing homes indicated that approximately 50% had a psychiatrist and a psychologist present at their site on a weekly basis. However, 90% of these providers were independent practitioners who were not formally affiliated with the long-term care facility (Molinari et al., 2009). Meanwhile, wellness programming, which aims to address the holistic needs of OALC members, is increasingly being implemented within OALCs, particularly in communities that provide ongoing care to older adults as their needs evolve. Those wellness initiatives are often focused on enhancing physical and social wellness (Edelman et al., 2010), frequently excluding other dimensions, including psychological or emotional well-being (Fullen, Wiley, et al., 2020).

Counselors who aim to work within OALCs should consider that some residents prioritize finding resources available on the community’s campus over seeking counseling services outside the community (Plys & Kluge, 2016). This suggests that until counseling services are offered in the OALC setting’s immediate vicinity, residents may continue to experience a barrier to access. Therefore, efforts are needed to integrate counseling services into the range of other on-site services offered directly to OALC residents (Fullen, Wiley, et al., 2020). Two other barriers are payment challenges and a dearth of training opportunities for working with older adults in counselor preparation programs.

Counselor Education, Training, and Supervision Challenges
     Developing counselor training opportunities to provide services for older adults, including those who reside in OALCs, is an additional barrier that must be addressed. Historically, the counseling profession has not adequately prioritized the counseling needs of older adults. For example, the 2016 Standards of the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) failed to include any reference to terms like old, older, older adults, or ageism, and only one reference each to the words age and aging (CACREP, 2015; Fullen, 2018). A content analysis of 26 years of research in the counseling profession indicated that only 1.6% of all publications focused on issues associated with aging (Fullen et al., 2019). However, following revisions to the Medicare mental health law, there have been recent indications that efforts to equip counseling students and counseling professionals to work with older adults are underway. The 2024 CACREP Standards include subtle improvements, such as including age and generational status in glossary definitions of diversity, cultural identity, and marginalized populations (CACREP, 2023). This reflects the viewpoint that older adults should not be overlooked in discussions of how social and cultural identities impact the needs of clients. There is evidence that exposure to working with older adults and greater self-efficacy around this work are associated with increased interest in working with older adults (Schmidt et al., 2024; Wagner et al., 2019). Likewise, Moye et al. (2019) found that psychologists expressed a strong interest in further gerontology education on depression, dementia, anxiety, bereavement, caregiver stress, and adjustment to medical illness or disability. These findings suggest that there is recognition of the need for greater emphasis on aging-related topics during training programs and beyond.

To address this shortage of training opportunities, developing partnerships between university-based mental health training programs and local OALCs is essential (Silva-Smith et al., 2011). Fortunately, OALCs near universities are common and university-based OALCs are popular among older adults (Gresham, 2024). Expanding counseling services in OALCs by embedding a mental health trainee represents an innovative approach to service delivery that is mutually advantageous for students, training programs, community residents, and the OALC (Fullen, Wiley, et al., 2020). Anecdotally, we have curated a counselor training program within a local OALC. Recognizing the need for emotional well-being supports, the counselor training program at Fullen’s university (Virginia Tech) partnered with a local OALC in 2018 to launch an innovative program in which graduate students in counseling provide pro bono counseling services to older adults. Individual, couples, and group counseling services are provided to residents in independent living, assisted living, skilled nursing, and long-term care, resulting in a diverse array of opportunities to address unmet mental health needs and promote emotional well-being.

This partnership alleviates cost barriers by enlisting graduate students who are completing their clinical internships. Accessibility concerns are mitigated by integrating the counseling services directly on the OALC campus. By making counseling available and visible within the community, stigma about working with older adult clients appears to be shrinking. Students are exposed to older adults’ mental health needs within their counselor training program using a strengths-based wellness model. This approach introduces students to the effectiveness of counseling services for older people while addressing myths about aging. Counseling services are advertised at the site’s health and wellness fair, at meet and greets, and in the OALC newsletter. Referrals from site staff or other residents are customary. Overall, the services have been well-received by residents of the community. The OALC, counselor training program, and counseling interns all report a high degree of program satisfaction.

Future Research
     There is considerable opportunity for future research to illuminate the impact of wellness counseling within OALCs. For example, outcome research on the use of a multidimensional wellness framework within OALCs, such as the eight-dimensional model previously described, is needed to demonstrate the utility and effectiveness of this approach to counseling. Similarly, research demonstrating whether certain wellness dimensions are prioritized more or less by OALC clients would be useful. If more counselor training programs are developed within OALCs, future research on the supervision of counselor trainees using wellness counseling within OALCs would be beneficial.

In addition to a focus on wellness counseling outcomes, more research on multicultural competence when working with OALC clients is necessary. For example, research is needed to improve the practice of broaching in the areas of age and ability, given the fact that most counselors and counselor trainees will hold chronological ages, and in some cases ability levels, that differ from their OALC clients. Studies are needed to better understand how counselors proactively engage their older adult clients in dialogue around age identity, age differences, ageism and ableism, and the potential for misunderstanding within the therapeutic relationship based on these differences.

Conclusion
     In conclusion, OALCs are an emergent setting for the delivery of wellness counseling services. The interest in wellness among industry leaders, combined with a growing awareness of the mental health needs of older adults, suggests that OALCs have a great deal of potential for counselors. By incorporating multidimensional wellness approaches that are responsive to the unique needs of older adults, counselors have an opportunity to expand their footprint and promote mental health and well-being across the lifespan.

 

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

 

References

Allen, J., Balfour, R., Bell, R., & Marmot, M. (2014). Social determinants of mental health. International Review of Psychiatry, 26(4), 392–407. https://doi.org/10.3109/09540261.2014.928270

Alzheimer’s Association. (2026). 2026 Alzheimer’s disease facts and figures. https://www.alz.org/getmedia/ef8f48f9-ad36-48ea-87f9-b74034635c1e/alzheimers-facts-and-figures.pdf

Argentum. (2016). Getting to 2025: A senior living roadmap. https://www.argentum.org/wp-content/uploads/2017/01/Argentum-2025-1.pdf

Ayalon, L. (2015). Perceptions of old age and aging in the continuing care retirement community. International Psychogeriatrics, 27(4), 611–620. https://doi.org/10.1017/S1041610214002415

Ayalon, L., & Greed, O. (2016). A typology of new residents’ adjustment to continuing care retirement communities. The Gerontologist, 56(4), 641–650. https://doi.org/10.1093/geront/gnu121

Ayalon, L., & Green, V. (2012). Grief in the initial adjustment process to the continuing care retirement community. Journal of Aging Studies, 26(4), 394–400. https://doi.org/10.1016/j.jaging.2012.05.001

Barry, K. L., & Blow, F. C. (2016). Drinking over the lifespan: Focus on older adults. Alcohol Research: Current Reviews, 38(1), 115–120. https://pubmed.ncbi.nlm.nih.gov/27159818

Bell, S., & Menec, V. (2015). “You don’t want to ask for the help” The imperative of independence: Is it related to social exclusion? Journal of Applied Gerontology, 34(3), NP1–NP21.
https://doi.org/10.1177/0733464812469292

Branson, J. S., Branson, A., Pozniak, K., Tookes, J., & Schmidt, M. (2019). The role of family during older adults’ living transitions: Implications for helping professionals and family counselors. The Family Journal, 27(1), 75–83. https://doi.org/10.1177/1066480718809418

Brecht, S. B., Fein, S., & Hollinger-Smith, L. (2009). Preparing for the future: Trends in continuing care retirement communities. Seniors Housing & Care Journal, 17(1), 75–90.

Brenes, G. A., Danhauer, S. C., Lyles, M. F., Hogan, P. E., & Miller, M. E. (2015). Telephone-delivered cognitive behavioral therapy and telephone-delivered nondirective supportive therapy for rural older adults with generalized anxiety disorder: A randomized clinical trial. JAMA Psychiatry, 72(10), 1012–1020. https://doi.org/10.1001/jamapsychiatry.2015.1154

Butler, R. N. (1969). Age-ism: Another form of bigotry. The Gerontologist, 9(4), 243–246.
https://doi.org/10.1093/geront/9.4_Part_1.243

Cacchione, P. Z., Eible, L., Gill, L. L., & Huege, S. F. (2016). Person-centered care for older adults with serious mental illness and substance misuse within a program of all-inclusive care for the elderly. Journal of Gerontological Nursing, 42(5), 11–17. https://doi.org/10.3928/00989134-20160413-04

Chaudhury, H., Hung, L., & Badger, M. (2013). The role of physical environment in supporting person-centered dining in long-term care: A review of the literature. American Journal of Alzheimer’s Disease & Other Dementias, 28(5), 491–500. https://doi.org/10.1177/1533317513488923

Christman, A. (2025). Non-profit CCRC occupancy gains paint “encouraging picture” for sector. https://seniorhousingnews.com/2025/08/13/non-profit-ccrc-occupancy-gains-paint-encouraging-picture-for-sector/ 

Consolidated Appropriations Act of 2023, Pub. L. 117-328, 136 Stat. 4459 (2023).

Corey, G. (2017). Theory and practice of counseling and psychotherapy (10th ed.). Cengage.

Council for the Accreditation of Counseling & Related Educational Programs. (2015). 2016 CACREP standards. https://www.cacrep.org/for-programs/2016-cacrep-standards

Council for the Accreditation of Counseling and Related Educational Programs. (2023). 2024 CACREP standards.
https://www.cacrep.org/wp-content/uploads/2024/04/2024-Standards-Combined-Version-4.11.2024.pdf

Creighton, A. S., Davison, T. E., & Kissane, D. W. (2016). The prevalence of anxiety among older adults in nursing homes and other residential aged care facilities: A systematic review. International Journal of Geriatric Psychiatry, 31(6), 555–566. https://doi.org/10.1002/gps.4378

Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics. The University of Chicago Legal Forum, 1989(1), 139–167. https://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8

Davis, J. D., Hill, B. D., Pillemer, S., Taylor, J., & Tremont, G. (2019). Guilt after placement questionnaire: A new instrument to assess caregiver emotional functioning following nursing home placement. Aging & Mental Health, 23(3), 352–356. https://doi.org/10.1080/13607863.2017.1423029

Day-Vines, N. L., Wood, S. M., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake, K., & Douglass, M. J. (2007). Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling & Development, 85(4), 401–409. https://doi.org/10.1002/j.1556-6678.2007.tb00608.x

Edelman, P., O’Brien, C., Loftus, E. M., & Engel, R. (2010). Whole person wellness in senior living: Perspectives of 23 pioneering communities. Seniors Housing & Care Journal, 18, 53–65.

Ferraro, K. F., Kemp, B. R., & Williams, M. M. (2017). Diverse aging and health inequality by race and ethnicity. Innovation in Aging, 1(1), 1–11. https://doi.org/10.1093/geroni/igx002

Fredriksen-Goldsen, K. I., Kim, H.-J., Bryan, A. E. B., Shiu, C., & Emlet, C. A. (2017). The cascading effects of marginalization and pathways of resilience in attaining good health among LGBT older adults.
The Gerontologist, 57(1), S72–S83. https://doi.org/10.1093/geront/gnw170

Fullen, M. C. (2016). Counseling for wellness with older adults. Adultspan Journal, 15(2), 109–123. https://doi.org/10.1002/adsp.12025

Fullen, M. C. (2018). Ageism and the counseling profession: Causes, consequences, and methods for counteraction. The Professional Counselor, 8(2), 104–114. https://doi.org/10.15241/mcf.8.2.104

Fullen, M. C. (2019). Defining wellness in older adulthood: Toward a comprehensive framework. Journal of Counseling & Development, 97(1), 62–74. https://doi.org/10.1002/jcad.12236

Fullen, M. C., Gorby, S., Chan, C. D., Dobmeier, R. A., & Jordan, J. (2019). The current state of gerontological counseling research: A 26-year content analysis. Journal of Counseling & Development, 97(4), 387–397. https://doi.org/10.1002/jcad.12287

Fullen, M. C., Lawson, G., & Sharma, J. (2020). Analyzing the impact of the Medicare coverage gap on counseling professionals: Results of a national study. Journal of Counseling & Development, 98(2), 207–219. https://doi.org/10.1002/jcad.12315

Fullen, M. C., Wiley, J. D., Delaughter, P. M., Jordan, J. R., Sharma, J., & Tomlin, C. C. (2020). Resident perspectives on the integration of a university-sponsored counseling program within a life plan community. Seniors Housing & Care Journal, 28(1).

Gendron, T. L., Welleford, E. A., Inker, J., & White, J. T. (2016). The language of ageism: Why we need to use words carefully. The Gerontologist, 56(6), 997–1006. https://doi.org/10.1093/geront/gnv066

Gitterman, A., & Knight, C. (2019). Non-death loss: Grieving for the loss of familiar place and for precious time and associated opportunities. Clinical Social Work Journal, 47(2), 147–155.
https://doi.org/10.1007/s10615-018-0682-5

Gresham, T. (2024, August 7). Why university retirement communities are gaining popularity among older adults. https://www.argentum.org/why-university-retirement-communities-are-gaining-popularity-among-older-adults

Hall, J., Kellett, S., Berrios, R., Bains, M. K., & Scott, S. (2016). Efficacy of cognitive behavioral therapy for generalized anxiety disorder in older adults: Systematic review, meta-analysis, and meta-regression. The American Journal of Geriatric Psychiatry, 24(11), 1063–1073. https://doi.org/10.1016/j.jagp.2016.06.006

Hettler, B. (1976). The six dimensions of wellness. https://members.nationalwellness.org/page/six_dimensions

Hummel, J., Weisbrod, C., Boesch, L., Himpler, K., Hauer, K., Hautzinger, M., Gaebel, A., Zieschang, T., Fickelscherer, A., Diener, S., Dutzi, I., Krumm, B., Oster, P., & Kopf, D. (2017). AIDE—Acute illness and depression in elderly patients. Cognitive behavioral group psychotherapy in geriatric patients with comorbid depression: A randomized, controlled trial. Journal of the American Medical Directors Association, 18(4), 341–349. https://doi.org/10.1016/j.jamda.2016.10.009

Johnson, J. (2025, June 26). The wellness equation in CCRCs: Reviving a core promise for successful aging.
https://www.mcknightsseniorliving.com/home/columns/marketplace-columns/the-wellness-equation-in-ccrcs-reviving-a-core-promise-for-successful-aging

Kattari, S. K., Lavery, A., & Hasche, L. (2017). Applying a social model of disability across the life span. Journal of Human Behavior in the Social Environment, 27(8), 865–880. https://doi.org/10.1080/10911359.2017.1344175

Kim, S. K., & Park, M. (2017). Effectiveness of person-centered care on people with dementia: A systematic review and meta-analysis. Clinical Interventions in Aging, 12, 381–397.
https://doi.org/10.2147/CIA.S117637

Krout, J. A., Moen, P., Holmes, H. H., Oggins, J., & Bowen, N. (2002). Reasons for relocation to a continuing care retirement community. Journal of Applied Gerontology, 21(2), 236–256.
https://doi.org/10.1177/07364802021002007

LaBauve, B. J., & Robinson, C. R. (2011). Adjusting to retirement: Considerations for counselors. Adultspan Journal, 1(1), 2–12. https://doi.org/10.1002/j.2161-0029.1999.tb00078.x

Martin, J. L., & Ancoli-Israel, S. (2008). Sleep disturbances in long-term care. Clinics in Geriatric Medicine, 24(1), 39–50. https://doi.org/10.1016/j.cger.2007.08.001

Medina, L., Sabo, S., & Vespa, J. (2020). Living longer: Historical and projected life expectancy in the United States, 1960 to 2060. United States Census Bureau.
https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25-1145.pdf

Molinari, V., Hedgecock, D., Branch, L., Brown, L. M., & Hyer, K. (2009). Mental health services in nursing homes: A survey of nursing home administrative personnel. Aging & Mental Health, 13(3), 477–486. https://doi.org/10.1080/13607860802607280

Moye, J., Karel, M. J., Stamm, K. E., Qualls, S. H., Segal, D. L., Tazeau, Y. N., & DiGilio, D. A. (2019). Workforce analysis of psychological practice with older adults: Growing crisis requires urgent action. Training and Education in Professional Psychology, 13(1), 46–55. https://doi.org/10.1037/tep0000206

Myers, J. E., & Degges-White, S. (2007). Aging well in an upscale retirement community: The relationships among perceived stress, mattering, and wellness. Adultspan Journal, 6(2), 96–110.
https://doi.org/10.1002/j.2161-0029.2007.tb00035.x

Nelis, S. M., Clare, L., Martyr, A., Markova, I., Roth, I., Woods, R. T., Whitaker, C. J., & Morris, R. G. (2011). Awareness of social and emotional functioning in people with early-stage dementia and implications for careers. Aging & Mental Health, 15(8), 961–969. https://doi.org/10.1080/13607863.2011.575350

Ogbonna, C. I., & Lembke, A. (2019). Substance use among older adults: Ethical issues. FOCUS, 17(2), 143–147. https://doi.org/10.1176/appi.focus.20180041

Ohrt, J. H., Clarke, P. B., & Conley, A. H. (2019). Wellness counseling: A holistic approach to prevention and intervention. American Counseling Association.

Plys, E., & Kluge, M. A. (2016). Life-space mobility in a sample of independent living residents within a continuing care retirement community with an embedded wellness program. Clinical Gerontologist, 39(3), 210–221. https://doi.org/10.1080/07317115.2015.1120251

Polenick, C. A., & DePasquale, N. (2019). Predictors of secondary role strains among spousal caregivers of older adults with functional disability. The Gerontologist, 59(3), 486-498.
https://doi.org/10.1093/geront/gnx204

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

Robinson, P., Giorgi, B., & Ekman, S.-L. (2012). The lived experience of early-stage Alzheimer’s disease: A three-year longitudinal phenomenological case study. Journal of Phenomenological Psychology, 43(2),
216–238. https://doi.org/10.1163/15691624-12341236

Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting and Clinical Psychology, 21, 95–103. https://doi.org/10.1037/0022-006X.60.6.827

Sacco, P., Burruss, K., Smith, C. A., Kuerbis, A., Harrington, D., Moore, A. A., & Resnick, B. (2015). Drinking behavior among older adults at a continuing care retirement community: Affective and motivational influences. Aging & Mental Health, 19(3), 279–289. https://doi.org/10.1080/13607863.2014.933307

Savva, G. M., & Arthur, A. (2015). Who has undiagnosed dementia? A cross-sectional analysis of participants of the Aging, Demographics and Memory Study. Age & Ageing, 44(4), 642–647.
https://doi.org/10.1093/ageing/afv020

Schmidt, N. E., Cottone, R. R., & Steffen, A. M. (2024). Working with older adults impacts training preferences of counselors. Gerontology & Geriatrics Education, 45(1), 86–91.
https://doi.org/10.1080/02701960.2022.2139693

Seidel, A., & Hedley, D. (2008). The use of solution-focused brief therapy with older adults in Mexico: A preliminary study. The American Journal of Family Therapy, 36(3), 242–252.
https://doi.org/10.1080/01926180701291279

Shippee, T. P. (2012). On the edge: Balancing health, participation, and autonomy to maintain active independent living in two retirement facilities. Journal of Aging Studies, (1), 1–15.
https://doi.org/10.1016/j.jaging.2011.05.002

Silva-Smith, A. L., Feliciano, L., Kluge, M. A., Yochim, B. P., Anderson, L. N., Hiroto, K. E., & Qualls, S. H. (2011). The Palisades: An interdisciplinary wellness model in senior housing. The Gerontologist, 51(3), 406–414. https://doi.org/10.1093/geront/gnq117

Sopcheck, J. (2020). Helpful approaches for older adults living in a retirement community to move forward after the death of a significant other. Journal of Social Work in End-Of-Life & Palliative Care, 16(3), 219–237. https://doi.org/10.1080/15524256.2020.1745352

Wagner, N. J., Mullen, P. R., & Sims, R. A. (2019). Professional counselors’ interest in counseling older adults. Adultspan Journal, 18(2), 70–84. https://doi.org/10.1002/adsp.12078

Wang, Y., Lou, Y., Shen, H.-W., & Gonzales, E. (2025). Intersectional discrimination and mental health in later life: Ageism as a core dimension. The Journals of Gerontology, Series B, 80(12).
https://doi.org/10.1093/geronb/gbaf184

Williams, J. M., Ballard, M. B., & Alessi, H. (2005). Aging and alcohol abuse: Increasing counselor awareness. Adultspan Journal, 4(1), 7–18. https://doi.org/10.1002/j.2161-0029.2005.tb00114.x

Wuthrich, V. M., Rapee, R. M., Kangas, M., & Perini, S. (2016). Randomized controlled trial of group cognitive behavioral therapy compared to a discussion group for co-morbid anxiety and depression in older adults. Psychological Medicine, 46(4), 785–795. https://doi.org/10.1017/S0033291715002251

 

Matthew C. Fullen, PhD, LPCC (OH), is an associate professor at Virginia Tech. Jonathan D. Wiley, PhD, LPC (VA), is an assistant professor at Tennessee Tech. Paul M. Delaughter, PhD, LPC (VA), is an assistant professor at Appalachian State University. Connie C. Tomlin, MA, LPC (TN), is the owner of Tomlin Counseling & Consulting. Jordan B. Westcott, PhD, NCC, is an assistant professor at the University of Tennessee-Knoxville. Nick Gowen, LPC (CO), is a counselor at Verve Therapy. Correspondence may be addressed to Matthew C. Fullen, Virginia Tech, School of Education, 1750 Kraft Drive, Blacksburg, VA 24061, mfullen@vt.edu.

Using Photovoice to Explore the Role of Self-Compassion in Mothers Post–COVID-19 Pandemic

Kelly Emelianchik-Key, Adriana C. Labarta, Clara Bossie, Carman S. Gill

Self-compassion, or the ability to show oneself kindness in challenging situations, has various advantages for mental well-being and psychological health, encompassing three interrelated elements: self-kindness, common humanity, and mindfulness. Mothers are an often-overlooked population who face numerous mental health challenges because of socially constructed ideals of motherhood. Therefore, mothers may encounter obstacles in developing self-compassion amid the demands of motherhood, related societal pressures, and other contextual factors, such as the COVID-19 pandemic. This research study utilized a photovoice methodology to investigate how mothers with children ages 5 to 12 experience self-compassion post–COVID-19 pandemic. The findings revealed four main themes with 13 subthemes, illustrating the distinct challenges and benefits associated with self-compassion for mothers. The authors conclude with implications for counseling, including the need for interventions that promote self-compassion and wellness for mothers from culturally and racially diverse communities.

Keywords: mothers, motherhood, self-compassion, photovoice, wellness

Intensive mothering, a term coined by Hays (1996), refers to the socially constructed expectation of motherhood that a mother must meet unrealistic standards to be deemed a good mother. Although societal roles have evolved over the past 30 years, with many mothers working full-time, the unrealistic ideal of motherhood has remained unchanged (Chae, 2014; Forbes et al., 2020; Lamar et al., 2019; Prikhidko & Swank, 2018). Intensive mothering demands that mothers be the central, self-sacrificing caregivers who devote extensive time, energy, and resources to their children’s needs (Hays, 1996). Forbes et al. (2021) asserted that the fact that “the expectations of mothers remain primarily unchanged despite advances made in gender equality in the U.S. as a result of feminist critiques suggests the expectations of mothers are deeply engrained in the fabric of society” (p. 271).

Research indicates that mothers from diverse backgrounds (e.g., race, ethnicity, social class, job status) endorse unrealistic beliefs about intensive mothering (Forbes et al., 2020), though cultural ideals, lack of resources, and structural barriers could impact the extent to which diverse communities endorse intensive mothering (Lankes, 2022). Living up to intensive mothering standards causes mothers to put children (and often the whole family) before their own mental and physical health (Elliot et al., 2015). Mothers who cannot live up to this ideal often face physical and mental health consequences, such as exhaustion, overwhelming anxiety, feelings of isolation and inadequacy, identity challenges and loss of self, self-criticism, and shame and guilt (Forbes et al., 2021; Prikhidko & Swank, 2018). They are also more likely to experience depression, anxiety, and decreased life satisfaction (Forbes et al., 2020; Prikhidko & Swank, 2018).

These pressures may lead mothers to engage in counseling to seek support, build realistic expectations, develop coping skills, and create a working family system that relies on more than one person to meet the needs of a child. Wellness, a cornerstone for effective counseling practice, focuses on the optimal health and well-being of the mind, body, and spirit, allowing individuals to live life more fully (Myers & Sweeney, 2004; Neff & Germer, 2013). Relatedly, maternal health strategies help support the physical, emotional, and mental health of mothers (Mitchell et al., 2018). Research suggests that mothers may benefit from focusing less on developing coping skills and more on developing maternal wellness strategies, such as having a plan and asking for help, which can impact the overall family system and functioning (Currie, 2018). The body of research on maternal wellness promotion in the counseling literature is not extensive, and there is a notable gap in empirical studies investigating how mothers’ well-being has been affected in the aftermath of the COVID-19 pandemic.

Dual Roles of Motherhood Post-Pandemic
     The COVID-19 outbreak was declared a pandemic in early March 2020. In late 2021, the World Health Organization (WHO) reported approximately 4.5 million deaths, with over 650,000 deaths in the United States alone (WHO, 2021). The COVID-19 pandemic’s impact ranged from being a manageable inconvenience for some to causing severe loss of lives and livelihoods for others, cutting across class, ethnic, and national boundaries (Park, 2021). As the COVID-19 pandemic became an inevitable daily reality, it increasingly highlighted pre-existing social disparities, including limited access to health care and education, which disproportionately affect marginalized communities. This was evident in the higher rates of cases, hospitalizations, and deaths among these groups (Centers for Disease Control and Prevention [CDC], 2020).

In a society already emphasizing intensive mothering, COVID-19 worsened gender inequalities, forcing women to take on additional home and childcare responsibilities, including homeschooling. More women left jobs because of these role changes (Alon et al., 2020; Bureau of Labor Statistics, 2021) and experienced higher rates of exhaustion, anxiety, and depression (Davenport et al., 2020; Grose, 2021). According to Grose’s (2021) article in The New York Times, 69% of mothers reported adverse health effects from COVID-19 pandemic–related stress, compared to 51% of fathers. The pandemic also intensified job disparities, with women facing more job losses and slower recovery than men, pre– and post–COVID-19 pandemic (Lofton et al., 2021). In dual-income households, mothers assumed greater childcare responsibilities than fathers, a trend that persisted throughout the COVID-19 pandemic (Zamarro et al., 2020). Hupkau and Petrongolo (2020) predicted that an unequal division of labor will perpetuate inequalities in parental roles. Although remote work allows women to balance work and family, it can dilute their workplace presence and negatively impact their careers. Increased domestic labor has led to worsening emotional and financial health for U.S. mothers (Bahn et al., 2020; Ruppanner et al., 2021). Therefore, addressing the intersection of motherhood and mental health is crucial for effectively addressing the post–COVID-19 pandemic impact.

Self-Compassion and Motherhood
     Given the prevalent challenges that mothers faced before, during, and after the COVID-19 pandemic, counselors need evidence-based approaches to promote wellness in community and clinical settings. Self-compassion comprises three dichotomous yet related components: mindfulness versus overidentification, common humanity versus isolation, and self-kindness versus self-judgment (Neff & Germer, 2013). Mindfulness is an evidence-based approach that entails nonjudgment and accepting one’s experiences rather than overidentifying or suppressing emotions (Neff, 2011). Common humanity describes the interconnectedness of the human experience and allows individuals to recognize pain and failure as universal struggles. Finally, self-kindness requires treating oneself with kindness, support, and understanding rather than engaging in self-criticism in response to life’s challenges (Neff, 2011).

Research has consistently linked lower levels of self-compassion with a range of mental health issues, including depression and anxiety (Han & Kim, 2023; Neff, 2011). As such, self-compassion may represent a powerful wellness construct because of its effectiveness in treating mental health concerns like anxiety, depression, stress, eating concerns, rumination, and self-criticism (Ferrari et al., 2019). Self-compassion may also represent an effective coping mechanism for mothers experiencing post-traumatic stress symptoms after childbirth (Mitchell et al., 2018), postpartum depression (Fonseca & Canavarro, 2018), and insecure attachment and parenting stress (Moreira et al., 2015; Neff, 2011). Furthermore, self-compassion may help mothers increase mental health, mindful parenting (Moreira et al., 2015; Neff, 2011), and the “ability to respond to the challenges of parenting in ways that are more sensitive and resilient” (Psychogiou et al., 2016, p. 897). Beyond individual benefits, emerging research has considered the intergenerational impacts of self-compassion (Carbonneau et al., 2020; Lathren et al., 2020). Mothers with greater self-compassion may better tolerate difficult emotions through kindness and nonjudgment, thereby better supporting their children in navigating distressing emotional experiences (Lathren et al., 2020).

Present Study

Because of the potential for new roles, increased responsibilities, and decreased support during and post–COVID-19 pandemic, mothers are at greater risk for mental health concerns (Bahn et al., 2020; Ruppanner et al., 2021). We believe that self-compassion is a promising tool for wellness-based counseling with mothers. Although the previous examples presented in our literature review reflected a few benefits of this practice, we sought to further explore the role and impact of self-compassion in mothers’ lives post–COVID-19 pandemic. In this study, we utilized photovoice, a method within community-based participatory research (CBPR) that draws on feminist theory, in order to better understand, empower, raise consciousness, create dialogue, and produce social change on behalf of mothers struggling with mental health and wellness post–COVID-19 pandemic (Wang, 1999; Wang & Burris, 1997).

Method

Grounded in feminism, critical pedagogy, and photography (Wang & Burris, 1997), photovoice is one of several qualitative research methods in CBPR that allows individuals to express their beliefs about community and social issues using photos and personal descriptions. This robust methodology promotes social action, diversity, and advocacy within communities (Smith et al., 2010; Wang & Burris, 1997). Photovoice assumes that participants are the experts in their own lives, with the research process involving three unique components: (a) facilitating a partnership within the community, developing a research question, and training; (b) reflecting on the images, adhering to critical pedagogy while using a structured analytical framework consisting of five questions, called SHOWeD, to guide the analysis and promote meaningful change; and (c) disseminating the findings within the community (Wang & Burris, 1997).

In counseling, photovoice has the power to promote critical ideologies and reflective dialogue that allows for the constructivist creation of meaning around a social construct, promoting social justice and advocacy within the community (Sackett & Jenkins, 2015; Wester et al., 2021). Additionally, research demonstrates that photovoice fosters team building, social skills, self-efficacy, social connectedness, friendship, empowerment, and a sense of community (Wang & Burris, 1997; Wilson et al., 2007). Scholars in the counseling profession have called for the use of photovoice to promote community and advocacy and investigate interventions for issues that inhibit client growth (Sackett & Jenkins, 2015). Because of this call, the strong ties to critical pedagogy, and the underpinnings of feminist theory, we used a photovoice methodology to explore the following research question: How do mothers in our community understand, experience, and enact self-compassion in their daily lives in a post–COVID-19 pandemic world?

Participants
     For the present study, the inclusion criteria indicated that participants must (a) be 18 years of age or older, (b) have no history of a personality disorder diagnosis and no severe symptoms of mental illness (e.g., suicidal ideation or psychosis), and (c) have at least one child in the home between the ages of 5 and 12. The rationale for selecting this age range was based on neurological data demonstrating differences in brain development for children over 5 (van der Kolk, 2014) and in Erikson’s psychosocial stages of development that document differences in individuals over 12 (Orenstein & Lewis, 2021). Our target sample size was eight to 12 participants, which was determined based on the standard for photovoice methodology (Wang & Burris, 1997), but additionally, the goal was to capture the depth and breadth of each individual analysis.

After excluding participants who did not complete the study or follow the study guidelines, the final sample consisted of eight women aged 30 to 42 (M = 37.25). Seven participants self-identified as White/Caucasian; one identified as Asian and White/Caucasian. All eight participants indicated that they were married. Participants were asked about their employment status and were given the option to select all applicable options. Five participants selected part-time employment, three marked stay-at-home parent, one indicated being employed full-time, and one indicated being self-employed. Regarding education level, four participants reported earning a bachelor’s degree or higher, two reported completing some college, one reported completing trade school, and one declined to respond. Lastly, concerning mental health concerns, two participants reported struggling with anxiety and depression, one reported struggling with attention-deficit hyperactivity disorder symptoms, three declined to respond, and two denied any mental health concerns.

Procedure
     After receiving IRB approval, we collaborated with two local community mental health agencies, including one nonprofit agency and one for-profit agency. These community-based mental health agencies allowed us to advertise and recruit mothers who met the criteria and demonstrated interest in this research. We shared electronic flyers via social media with the study information, including the design, purpose, and participant expectations (i.e., taking photos and discussing the meaning behind them in focus groups). We also provided a small allotment to compensate for participants’ costs, such as internet or cell phone data use. The for-profit agency also offered free self-compassion books to all participants who completed the study. Participants could receive this resource by providing their email addresses after their final interview.

After completing an informed consent form, each participant participated in a 45–60-minute psychoeducational focus group led by one or more members of our research team, where they learned the basic components of self-compassion (i.e., self-kindness, common humanity, and mindfulness) and engaged in discussions about self-compassion with other group members. These psychoeducational groups consisted of two to four participants because of the scheduling needs of participants. Our overarching research question for the study was shared and we engaged in dialogue about changes experienced because of the COVID-19 pandemic. At the end of the session, we provided participants with information about taking photos, directions, and information to assist in maintaining confidentiality (e.g., avoid taking photos of self or others to protect confidentiality). The participants had 10 days to take or select photos to visually describe self-compassion in their own lives. Following, each participant was asked to caption them with a title, respond to the SHOWeD questions, which are unique to the methodology, and send them to us via email. The SHOWeD questions consisted of the following: 1) What do you see in the photo? 2) What is happening in your photograph? 3) How does this photo capture self-compassion in your own life? 4) Why does this photo contribute to the challenge, concern, or strengths that exist in self-compassion? and 5) What can mental health professionals or others do to help foster and support self-compassion in mothers? (Wang & Burris, 1997).

Each participant completed a follow-up photovoice session in which we placed participants’ top two selected photos on a slideshow with their corresponding captions. We followed outlined guidelines for the second photovoice session (Wang & Burris, 1997; Wester et al., 2021) while focusing on the two photos each participant selected, which were used to establish themes. Most of the second photovoice sessions were held individually to give mothers more scheduling flexibility and prevent further attrition. Although these in-depth, semi-structured interviews were individual, participants were encouraged to engage in dialogue with our research team regarding other participants’ photos and captions in order to create shared meaning. Once the meeting ended, we transcribed the entire discussion while focusing on the participants’ meaning of the photos.

Data Analysis
     This study used photovoice, a methodology within CBPR (Wang, 1999; Wang & Burris, 1997), and interpretative phenomenological analysis (IPA) to explore participants’ experiences within interview transcripts and photographs (Burton et al., 2017; Griffin & May, 2012). The study emphasized collaboration between researchers and community members throughout the research process, from defining research questions to disseminating findings. This approach ensured the research was relevant to and beneficial for the community it aimed to serve. The feminist framework underpinned the entire process, influencing the focus on gender issues and power dynamics, emphasizing participants’ voices and lived experiences, and promoting social change and empowerment (Wang, 1999). IPA was utilized as the primary analytical approach, aligning with the study’s aim to explore how participants make sense of their experiences (Burton et al., 2017). Participants were viewed as experts in their own experiences, and the analysis focused on understanding their perspectives.

Following the IPA procedures of Griffin and May (2012), the analysis began with thorough familiarization with the data, followed by initial coding, developing emergent themes, searching for connections, and looking for patterns across cases. Recurring patterns and key concepts were identified in each transcript, photo, and responses to the SHOWeD questions. Relationships between themes found in the written dialogue and patterns in photos were extracted, always keeping in mind the true meaning expressed by the participants. We engaged in a double hermeneutic process, interpreting the participants’ interpretations of their experiences. Interpretive themes were developed to analyze deeper meaning. All four of us met weekly during the coding process to discuss each step and reach a consensus before moving on to each next step (Larkin & Thompson, 2011).

Role of the Researcher and Trustworthiness
     Trustworthiness is critical in qualitative research. To promote transparency as the research team, we identified our backgrounds and identities, which could impact the study (Creswell, 2020). Our team consisted of four members: three coders and one auditor. Kelly Emelianchik-Key (associate professor), Adriana C. Labarta (assistant professor), and Carman S. Gill (full professor) served as coders and were all counselor educators at Florida Atlantic University during the research process. They are each licensed mental health counselors, National Certified Counselors, and Approved Clinical Supervisors; Emelianchik-Key is also a licensed marriage and family therapist. Emelianchik-Key and Gill identify as White females and Labarta identifies as Latina. Emelianchik-Key also identifies as a mother, which was a critical piece of the study and important to consider to prevent bias. The auditor, Clara Bossie, is a White female and a counselor education doctoral student at Florida Atlantic University; she is a licensed marriage and family therapist with specialized training in dialectical behavioral therapy and as a Mindful Self-Compassion (MSC) teacher. She is also the owner and clinical director of a private practice.

Emelianchik-Key, Labarta, and Gill have extensive experience in qualitative research and coded the data, while Bossie served as an external auditor because of her specialized MSC training in order to provide additional perspectives and feedback, enhancing trustworthiness (Creswell & Báez, 2020). As a team, we discussed biases and assumptions throughout the research and data analysis process, maintaining an audit trail. Peer validation was used to promote trustworthiness (Larkin & Thompson, 2011) while noting intersectionality and privilege within the team. Member checking was conducted after developing the final themes, with participants providing feedback. No objections were raised, and two of the participants responded noting they agreed with the results.

Results

The findings that emerged from the discussion of the SHOWeD questions, participant photos, and corresponding captions included four overarching themes with 13 subthemes. Theme 1, Challenges With Self-Compassion, included subthemes Permission and Justification, Making Time, Self-Worth, and Understanding Self-Compassion. Theme 2, Isolation Versus Common Humanity, included subthemes Social Media, Desire for Connection, and Self-Criticism. Theme 3, Awareness and Education, included the subthemes Self-Awareness, Acknowledgment From Self and Others, and Psychoeducation. Theme 4, Mindfulness, included subthemes Open Awareness, One-Pointed Awareness, and Tactile Experiences.

Theme 1: Challenges With Self-Compassion
     The initial theme revolved around mothers’ obstacles and difficulties with integrating self-compassion into their daily lives. These challenges encompassed permission giving, allocating time, grappling with feelings of self-worth, and distinguishing between self-compassion and self-care. The subtheme of Permission and Justification encompassed the hurdles mothers encounter when attempting to incorporate self-compassion into their lives. A common rationale for practicing self-compassion was the significant impact it may have on their children and families. Mothers expressed challenges with practicing self-compassion “just because” and sought justifications for their practice. The second subtheme of Making Time underscored the challenge of making time for self-compassion amid juggling various roles and responsibilities as a mother. Moreover, this subtheme emerged during our study because of the difficulty in finding mothers to participate amidst their many demands. Rather than making time for themselves, mothers described examples of wedging acts of self-compassion into everyday activities, such as morning coffee and reflective moments in the car during Little League practice.

The third subtheme of Self-Worth underscored mothers’ difficulties in recognizing their value, particularly as they navigate societal and familial expectations of the “perfect” mother. Participants expressed sentiments of needing to validate or “prove” their worthiness. The last subtheme of Understanding Self-Compassion shed light on the difficulty of discerning between self-care and self-compassion. Participants frequently equated self-care activities with self-compassion, failing to distinguish between them and often neglecting their needs. The self-compassion practices described by participants were not entirely directed toward their well-being, as evidenced by self-care activities and compassion practices that primarily sought to extend warmth and kindness to others rather than focusing on themselves. Examples from these subthemes are in Table 1.

Table 1

Participant Quotes Related to Subthemes of Theme 1: Challenges With Self-Compassion

Subthemes Participant Quote
Permission and Justification Participant 3: “It’s been really important for me to find time for myself to do things that I want to do. But then I feel like sometimes, as a mom, you feel like everything revolves around your family, and then, when you take time away from that, it’s like you’re being selfish.”
Making Time Participant 2: “It’s hard to remember sometimes when you’re on autopilot. Yeah, or things happen like one after another, and then you don’t have that awareness right away sometimes.”
Self-Worth Participant 3: “I feel like I’m always trying to prove that what I do is important. And it’s not only proving that to other people, but I need to feel it myself.”
Understanding Self-Compassion Participant 1: “I think even like understanding self-compassion can be kind of strange, because nowadays it’s self-care. Everyone calls it ‛self-care.’ It seems like just everyone is getting their nails done or paying for expensive facials, or whatever, because it’s self-care. I think that’s kind of more of like a superficial thing, where self-compassion is more internal . . . you have to like, you know, be self-aware to know how to be self-compassionate.”

 

Theme 2: Isolation Versus Common Humanity
     The second theme highlighted one of the central components of the self-compassion model: Isolation Versus Common Humanity (Germer & Neff, 2019; Neff & Germer, 2013). This theme showcased the contrast between participants’ longing for connection while engaging in behaviors that fostered disconnection. The first subtheme was Social Media, including its positive and negative impacts. A significant aspect was the experience of social comparisons, which either provided participants with understanding and validation or left them feeling isolated and separate from others, resulting in self-criticism. Social media had both helpful and harmful influences on participants’ well-being.

The second subtheme of Desire for Connection reflected participants’ deep longing to connect with others and to feel heard, valued, and acknowledged for their efforts. This is especially true when navigating parenting challenges to avoid feelings of isolation. The last subtheme was Self-Criticism. Self-criticism captured instances in which mothers engaged in or exhibited self-critical language. Participants frequently engaged in cognitive distortions such as overgeneralizing, ruminating on “should haves,” and making self-judgments. This tendency toward self-criticism often led to narratives and expressions of isolation or feeling excluded from a group or family. Participant quotes for each of these subthemes are found in Table 2.

Table 2 

Participant Quotes Related to Subthemes of Theme 2: Isolation Versus Common Humanity

Subthemes Participant Quote
Social Media Participant 2: “I think the reason self-compassion isn’t as popular is because a lot of the mainstream help we easily come across makes a profit on people feeling like they’re not good enough. Self-compassion doesn’t count on people needing to take a big action to make a change in their lives.”
Desire for Connection Participant 5: “The overall experience was good. . . . It’s always nice to hear that you’re not the only person juggling a thousand things and trying to make sense of it.”
Self-Criticism Participant 6: “Sometimes we all feel like we’re alone in the things that we’re doing and the things that we’re dealing with because we can’t feel like we can talk about it cause then we’re a failure. And that’s like one of the biggest things for moms.”

 

Theme 3: Awareness and Education
     The third theme encapsulated participants’ journey toward cultivating heightened self-awareness regarding the importance of self-compassion, alongside a plea for counselors to provide enhanced education and incorporate strengths-based, empowering approaches for mothers. The first subtheme of Self-Awareness involved participants recognizing the significance of self-compassion and their ability to prioritize time for engaging in self-compassion and self-care. Participants acknowledged that seeking help is permissible and that the shaming associated with being unable to manage everything should not occur. The second subtheme of Acknowledgment From Self and Others centered around the desire to be recognized and valued for their many roles as mothers, spouses, breadwinners, etc., while embracing self-kindness and self-validation. The last subtheme of Psychoeducation emerged as participants emphasized the necessity for greater awareness and understanding of self-compassion and its relevance in daily life. Specifically, they stressed the importance of making this knowledge more accessible for mothers and the need for others to be educated about the challenges mothers face. Example quotes from these subthemes are in Table 3.

Theme 4: Mindfulness
     The fourth theme explored the various methods by which participants incorporated mindfulness activities as part of their practice of self-compassion. The first subtheme, Open Awareness, addressed the specific ways participants engaged in mindfulness activities that allowed them to become more aware of the entire environment. Some participants participated in mindfulness activities that heightened their awareness of their surroundings, although this engagement focused more on relationship mindfulness than self-compassion. The second subtheme of One-Pointed Awareness described participants’ mindfulness practices with focused awareness, concentrating solely on one aspect of the present moment. They fully immersed themselves in the mindfulness practice, recognizing it as a means of personal growth. The last subtheme of Tactile Experiences illustrated participants’ self-soothing or grounding practices involving multiple senses, particularly touch, sensation, smell, and profound observation. These practices typically occurred in the morning and often included enjoying coffee, gardening, or immersing oneself in nature. A sample quote from each subtheme is in Table 4.

Table 3 

Participant Quotes Related to Subthemes of Theme 3: Awareness and Education

Subthemes Participant Quote
Self-Awareness

 

 

Participant 7: “We’d taken a picture of my daughter’s little emotion dolls, or like some animals . . . I’m like, ‛well, that’s perfect.’ Because you know, we all have these emotions. . . . So that really stood out to me, because that’s something that I’ve really learned becoming a parent and a mom . . . we are going to have these emotions. It’s okay to have emotions and that’s something I’ve been, you know, trying to teach my kids to a lot of the time . . . that was a big self-compassion thing that stood out to me was, you know, letting myself feel like, you know, anger or frustration, or all the other ones that were lined up in that picture.”
Acknowledgment From
Self and Others
Participant 3: “I think, that just hearing like, ‛Hey, I see you. I see that you’re working hard, and you’re doing great,’ you know. So I think that that’s what moms need to hear.”
Psychoeducation Participant 8: “Just educating mothers more on like the postpartum journey and normalizing, you know, postpartum depression and postpartum anxiety. . . . I don’t necessarily feel like I was properly educated while I was pregnant, and then postpartum on, you know, how much you, your hormones and everything, it affects you mentally, especially in this world with social media. And you know, everyone’s perfect. And you know, everyone wakes up the next day after, you know, not sleeping with a newborn all night and being exhausted. And you’re supposed to look perfect and act perfect. And you know, I just wish there was more acceptance and kind of education and normalizing the raw journey of postpartum.”

 

Table 4 

Participant Quotes Related to Subthemes of Theme 4: Mindfulness

Subthemes Participant Quote
Open Awareness Participant 8: “I do struggle a lot with my body image as a woman. And just, you know, after you have children and your body changes. So, for me, this photo is also really powerful in that aspect, because I’ve been doing a lot of work with that as well as just not being as hard on myself. And you know, normally, I would be like super uncomfortable at the beach, and especially because it was like a packed day. It was Mother’s Day, wearing a bathing suit, and I just didn’t give a shit, and it was really cool. And I just, I think, because I was just so immersed with my family and being present.”
One-Pointed Awareness Participant 2: “Just paying attention to your body. And if I feel I’m breathing a little shallow, sometimes I notice I’m holding my breath, and sometimes I notice that my shoulders are up here, and that’s usually my little sign to like, okay . . . this doesn’t feel good. Let’s fix this for a minute. Do something.”
Tactile Experiences Participant 4: “We just moved into this house 6 months ago, and I love flowers. And you know, I missed my old house with like my garden, so I had to start over. . . . That’s like my thing. I literally go out there and do that every single morning. I mean, sometimes it’s 3 minutes, sometimes it’s 15 minutes, but mainly it’s 5 minutes. But that’s where I was like, yeah, that’s my time. You know, where I don’t bring the phone out there with me.”

 

Data Presentation to Stakeholders
     Consistent with CBPR goals and photovoice procedures (Wang & Burris, 1997; Wester et al., 2021), we sought to promote change and advocate for mothers by sharing our findings with stakeholders. The stakeholders included the nonprofit community-based agency and private practice that helped recruit participants, and a group of local counselors affiliated with a large community agency who could further increase awareness, co-create meaning, and facilitate change. The study participants were invited to join our meeting with stakeholders who participated in a presentation of the findings, including PowerPoint slides illustrating the primary themes and participant photos. The last question of the SHOWeD method was especially considered: “What can mental health professionals or others do to help foster and support self-compassion in mothers?” We engaged in a collaborative dialogue on implementing the study’s findings into practice, which are further elaborated in the discussion section of this manuscript.

Discussion

Mothers, often serving as the backbone of their families, face silent battles with mental health and identity, heightened by sociocultural ideals and other contextual factors like the recent COVID-19 pandemic’s isolating conditions (Chae, 2014; Davenport et al., 2020; Grose, 2021; Neff, 2011; Prikhidko & Swank, 2018). Mothers’ quiet struggles illuminate an alarming need for more mental health support tailored to the unique experiences of motherhood. Our study explored mothers’ experiences post–COVID-19 pandemic with cultivating self-compassion using photovoice, revealing four overarching themes: (a) Challenges With Self-Compassion, (b) Isolation Versus Common Humanity, (c) Awareness and Education, and (d) Mindfulness.

The first theme suggests that mothers’ challenges with self-compassion are deeply entangled in the daily realities of motherhood and exacerbated by societal ideals. These difficulties extend beyond finding time (which was extremely limited) for self-care; instead, they reflect more profound issues of how mothers perceive and treat themselves amid overwhelming external expectations, often compromising their well-being and prioritizing their children and families (Forbes et al., 2021; Lamar et al., 2019). Feminist theory recognizes how gendered expectations of motherhood create structural time poverty, but the lack of self-compassionate practices calls attention to the systemic issues about women’s unpaid labor and societal expectations. The subtheme of Permission and Justification manifested itself through the notion of self-compassion to “model it” for their children rather than themselves, which aligns with previous research (Lathren et al., 2020). A complex interplay of self-neglect and societal pressures led mothers to conflate the concept of self-care with self-compassion. Consequently, mothers frequently and erroneously equate self-care activities with self-compassion. This misunderstanding underscores the need for psychoeducation on self-compassion in counseling. Although self-care is essential to address one’s immediate needs, self-compassion embodies a more profound, forgiving, and accepting approach to our limitations and failures (Neff, 2011).

The second theme, Isolation Versus Common Humanity, highlights one of the primary components of the self-compassion model (Germer & Neff, 2019; Neff & Germer, 2013) and extends prior research on the impact of social comparison and media on mothers (Chae, 2014; Prikhidko & Swank, 2018). Participants described a dichotomy between the desire to connect with others while grappling with social comparison, thus leading to feelings of inadequacy and isolation. Participants acknowledged the benefits of social media (e.g., accessibility) while simultaneously struggling with the overwhelmingly “positive” and “happy” images in contrast to content addressing the challenges of motherhood. Mothers sought authentic, meaningful connections beyond social media and surface-level interactions. This finding underscores the need for counselors to foster nonjudgmental and compassionate spaces for mothers to connect on their shared experiences and struggles. Additionally, intentional engagement in mindfulness is critical for feelings of isolation that stem from social media usage. This approach can encourage mothers to become more aware of the images they engage with and facilitate the positive benefits of social media. Feminist frameworks emphasize the importance of recognizing personal struggles as connected to broader social patterns, so difficulties connecting with common humanity may also reflect the individualistic messaging mothers receive about “doing it all.”

Awareness and Education, the third theme of our study, was at the forefront of our interviews with participants. Mothers expressed excitement about the construct of self-compassion, leading to critical discussions on the need for more psychoeducation on this practice. Given the abundant research that supports self-compassion as a means of developing mental health and wellness (Ferrari et al., 2019; Fonseca & Canavarro, 2018; Lathren et al., 2020; Mitchell et al., 2018; Moreira et al., 2015), greater access to treatment and resources is crucial to mitigate mothers’ challenges to practicing self-compassion, particularly at the community level. For instance, counselors can use social media platforms to provide psychoeducation on self-compassion, share helpful resources, and foster supportive communities that challenge the “illusion of perfection” (Neff, 2011, p. 70).

The fourth theme underscores how Mindfulness and Self-Compassion are inextricably linked (Neff, 2011; Neff & Germer, 2013). Regardless of how mothers practiced mindfulness (e.g., Open Awareness, One-Pointed Awareness, or Tactile Experiences), it allows them to connect more deeply with their experiences by accepting difficult emotions, becoming more aware of their environment, or engaging the senses. However, it is essential to note that mindfulness and self-compassion do not automatically co-occur. Neff and Dahm (2015) indicated:

It is possible to be mindfully aware of painful thoughts and feelings without actively soothing and comforting oneself or remembering that these feelings are part of the shared human experience. Sometimes it takes an extra intentional effort to be compassionate toward our own suffering, especially when our painful thoughts and emotions involve self-judgments and feelings of inadequacy. (p. 130)

Neff and Dahm’s assertion highlights that while mindfulness fosters awareness, self-compassion requires additional intentionality, particularly in the face of self-judgment. Building on this, counselors play a vital role in educating mothers on the all-encompassing practice of self-compassion, which goes beyond mindful awareness to include self-kindness and a recognition of common humanity. This is especially important in addressing societal and cultural expectations that are contrary to “slowing down,” being kind to oneself, and recognizing one’s connection with others.

Implications for Counselors
     The findings of this study illuminate the need for a multifaceted approach to helping mothers cultivate self-compassion and wellness. Although most participants’ narratives did not explicitly address self-compassion practices and connection to the COVID-19 pandemic, counselors should carefully consider how the additional responsibilities and stressors that emerged during this period may have become normalized and integrated into mothers’ daily lives. The minimal direct pandemic references in participants’ responses may be telling, suggesting that what began as temporary adaptations to crisis have potentially evolved into enduring expectations and workload increases for mothers. This has important implications for how counselors conceptualize and address maternal stress, role strain, and work–life integration in their practice.

Counselors must establish trust, safety, and rapport with mothers to discuss challenging topics such as self-doubt, isolation, and self-worth. Counselors can demonstrate the differences between self-compassion and self-care. For example, although self-care may help to temporarily disconnect after a difficult day (e.g., watching an entertaining television series), self-compassion encourages mothers to become curious about their inner emotional experiences (mindfulness), utilize sources of support (common humanity), and respond to uncomfortable emotions with acceptance and warmth (self-kindness). Counselors may consider various approaches to integrating self-compassion into their work and communities, from offering courses as an MSC-trained teacher (Germer & Neff, 2019) to utilizing The Mindful Self Compassion Workbook: A Proven Way to Accept Yourself, Build Inner Strength, and Thrive (Neff & Germer, 2018) and online resources available through the Center for Mindful Self-Compassion. MSC integrates the practice of mindfulness with the nurturing qualities of self-compassion, creating a potent approach for cultivating emotional resilience. MSC combines mindfulness with nurturing self-compassion to build emotional resilience, improving overall physical wellness while reducing anxiety, depression, and burnout (Germer & Neff, 2019), making it especially valuable for mothers with limited mental health access.

Therapeutic modalities that explore underlying factors contributing to mothers’ reluctance or hesitation to engage in self-compassion practices, such as past experiences, societal expectations, or cultural influences, may increase the effectiveness of programs like MSC. Our participants indicated deeply ingrained negative beliefs about themselves, which can hinder their ability to practice self-compassion. Counselors can help mothers identify and challenge these beliefs, encouraging them to develop more compassionate and realistic self-perceptions through insight-oriented practices, such as Socratic questioning, motivational interviewing, and self-reflective practices.

Though MSC offers therapeutic benefits, it’s not therapy itself. Unlike our study participants who were prepared for vulnerability, counselors must recognize that mothers come with varying needs. Germer and Neff (2019) emphasized that effective MSC delivery depends on a client’s tolerance zone, which includes being in a safe, challenged, or overwhelmed state, with optimal learning occurring in safe or challenged states where clients can progress through acceptance stages while maintaining emotional regulation. Opening oneself to self-compassion may lead to “backdraft,” when individuals encounter previously suppressed painful emotions (Germer & Neff, 2019). Although most mothers can embrace self-compassion practices immediately, some in clinical populations may need deeper therapeutic work as preparation (Neff & Germer, 2018). In addition to the challenges and pressures of motherhood, mothers may arrive with various co-occurring issues such as grief, mental health concerns, complex trauma, or other shame-invoking experiences lying just below the surface (Neff, 2011). It is important that counselors are prepared to utilize evidence-based treatment approaches to help mothers fully access self-compassion practices and handle potential backdrafts.

Theoretical Integration
     Integrating a self-compassion–informed approach into counseling is greatly enhanced by drawing from evidence-based approaches that align with the construct of self-compassion, such as acceptance and commitment therapy (ACT), compassion-focused therapy (CFT), mindfulness-based cognitive therapy (MBCT), dialectical behavior therapy (DBT), and Adlerian theory. These therapeutic models support the development of self-compassion, a key aspect of MSC, by promoting emotional resilience, self-awareness, and adaptive coping mechanisms. Gilbert (2014) developed CFT to explicitly target
self-criticism and shame while promoting the cultivation of self-compassion through exercises designed to enhance compassionate self-awareness. CFT provides structured techniques to cultivate a kind and understanding inner voice, benefiting clients with harsh self-judgment. Similarly, Adlerian theory’s holistic social perspective emphasizes social connectedness and community feeling (Adler, 1938), aligning with MSC’s principle of common humanity that recognizes suffering as a shared human experience. By fostering a sense of belonging and encouraging clients to develop self-compassion within the context of their social relationships, Adlerian theory enhances the application of MSC in promoting overall well-being. Moreover, third-wave cognitive-behavioral models are widely praised for integrating validation, mindfulness, and self-acceptance that support self-compassion–informed counseling. ACT’s emphasis on mindfulness and acceptance aligns with self-compassion by encouraging clients to accept their thoughts and feelings without judgment and commit to values-based actions (Hayes et al., 2006). This approach promotes a compassionate stance toward oneself, central to Germer and Neff’s (2019) MSC program. By fostering curiosity and kindness toward internal experiences, ACT helps integrate self-compassion practices into daily life (Hayes et al., 2006). MBCT combines cognitive strategies with mindfulness practices, making it a natural ally to MSC. By teaching clients to recognize and break free from patterns of depressive rumination, MBCT enhances clients’ ability to respond to difficult emotions with mindfulness and self-compassion (Segal et al., 2018). This supports clients in emotional balance and resilience, essential components of MSC (Segal et al., 2018). Lastly, DBT and MSC share core principles. DBT’s mindfulness emphasis and dialectical approach of balancing acceptance with change aligns with MSC, offering robust tools for navigating emotional turbulence through self-acceptance and compassion (Linehan, 2014). 

Multicultural Considerations and Future Implications
     One important consideration is that we recruited participants from local mental health agencies, with the final sample being predominantly White. Participation challenges arose primarily for women of color recruited via social media, including declining participation and dropout because of time constraints. Forbes et al. (2020) noted that the experience of intensive mothering was consistent across various maternal demographics (i.e., race, ethnicity, social class upbringing, relationship status, number of children, and job status). However, Lankes (2022) distinguished that the significance and impact of intensive mothering can vary depending on cultural ideals, resource availability, and structural barriers. This means that mothers from marginalized or underserved communities who face heightened societal stressors and systemic barriers may experience impediments to engaging in self-care practices and accessing mental health resources. Thus, the compounding effects of racism, discrimination, and the unique pressures associated with motherhood can exacerbate mental health challenges and diminish opportunities for cultivating self-compassion and well-being (Condon et al., 2022). Counselors must provide culturally responsive care that acknowledges their clients’ unique, intersectional identities and the historical and current context of oppression and marginalization. Overall, counselors can advocate for policies and systemic changes for underserved mothers, such as by offering self-compassion workshops for mothers in the community, thus increasing access to services.

Community Conversations
     After completing the study, we sought expert validation by presenting our findings to a local community agency through a research presentation and interactive dialogue. We invited clinicians with expertise in self-compassion, family counseling, parenting, women’s issues, and vulnerable populations to share their reactions based on clinical experiences and to offer recommendations. The attending clinicians validated the four overarching themes of our study, sharing stories of motherhood marked by self-criticism, judgment, and expectation. Participants were also invited to this meeting as part of our CBPR methodology. Clinicians who identified as professionals and mothers resonated with the study’s themes, sharing personal narratives that aligned strongly with our findings. They discussed strategies to help their clients, particularly mothers, practice self-compassion, including curating social media feeds (e.g., Instagram) to avoid disempowering content that perpetuates comparison and self-criticism. Additionally, they emphasized the importance of psychoeducation from a systems perspective, suggesting mindfulness and self-compassion as powerful tools for family wellness, and acknowledged the challenges and strengths of mothers. Although no participants opted to attend because of scheduling challenges (finding time was an overarching challenge for participants throughout the study), final thoughts and comments on how this information can impact our work was discussed with community clinicians. Overall, these discussions affirmed the study’s findings and support the need for ongoing research and advocacy initiatives to raise awareness and increase access to self-compassion practices for mothers.

Following expert validation, a nationally recognized treatment center invited us to co-host an experiential seminar open to counselors and community members. The seminar, held in an underserved community, provided an overview of the study’s findings, self-compassion principles, and experiential exercises. We distributed learning materials to participants, and we offered recommendations for integrating self-compassion into daily life, family relationships, and clinical practice. As part of our ongoing efforts to disseminate the findings and advance community advocacy, the research team presented the results at a national conference, which sparked further conscious conversations, reinforcing our commitment to supporting mothers in underserved communities.

Limitations and Future Research
     The present study is not without limitations. Although the nature of photovoice calls for focus groups (Wang & Burris, 1997; Wilson et al., 2007), we decided to meet with participants in smaller groups or individually to accommodate busy schedules. Although the format provided flexibility, the individual interviews can limit dialogue and community building. Additionally, our participants were too busy to attend our community meetings—a crucial component of CBPR. Future research can replicate our study using focus groups, which may provide additional insights into mothers’ self-compassion practices. Researchers may want to consider providing childcare to assist with finding time. Another limitation was a lack of racial and ethnic diversity, as our sample mainly included White women connected to counseling communities. Future research can explore the experiences of mothers with diverse racial, sexual, affectional, and marital backgrounds with self-compassion through photovoice. Mothers with intersecting identities face additional challenges, such as discrimination and systemic inequities, further impacting mental health and parenting stress (Condon et al., 2022). Wellness interventions, like self-compassion skills, could help bridge health disparities for diverse mothers.

Conclusion
     Self-compassion is essential for psychological well-being. Mothers face numerous mental health challenges due to societal expectations and contextual factors, such as post–COVID-19 pandemic shifts in work–life balance, and may encounter obstacles in cultivating self-compassion. The findings reveal the unique challenges and benefits of self-compassion for mothers and the mismatch between the understanding of self-compassion and its practice in daily life. A comprehensive and multidimensional approach is necessary to assist mothers in developing self-compassion and promoting their overall well-being. Counselors must find ways to educate clients and foster this critical skill in mothers, who can often be overlooked, overburdened, and unintentionally undervalued.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
for the development of this manuscript.
Florida Atlantic University provided a small
grant to the researchers for community-engaged
research projects.
 

References

Adler, A. (1938). Social interest: A challenge to mankind. Faber & Faber.

Alon, T., Doepke, M., Olmstead-Rumsey, J., & Tertilt, M. (2020). The impact of COVID-19 on gender equality (Working Paper 26947). National Bureau of Economic Research. https://doi.org/10.3386/w26947

Bahn, K., Cohen, J., & van der Meulen Rodgers, Y. (2020). A feminist perspective on COVID-19 and the value of care work globally. Gender, Work, & Organization, 27(5), 695–699. https://doi.org/10.1111/gwao.12459

Bureau of Labor Statistics. (2021). The employment situation—January 2021 (Publication No. USDL-21-0142).
https://www.bls.gov/news.release/archives/empsit_02052021.pdf

Burton, A., Hughes, M., & Dempsey, R. C. (2017). Quality of life research: A case for combining photo-elicitation with interpretative phenomenological analysis. Qualitative Research in Psychology, 14(4), 375–393.
https://doi.org/10.1080/14780887.2017.1322650

Carbonneau, N., Goodman, L. C., Roberts, L. T., Bégin, C., Lussier, Y., & Musher-Eizenman, D. R. (2020). A look at the intergenerational associations between self-compassion, body esteem, and emotional eating within dyads of mothers and their adult daughters. Body Image, 33, 106–114.
https://doi.org/10.1016/j.bodyim.2020.02.007

Centers for Disease Control and Prevention. (2020). COVID-19 hospitalization and death by race/ethnicity.
https://stacks.cdc.gov/view/cdc/97937

Chae, J. (2014). “Am I a better mother than you?” Media and 21st-century motherhood in the context of the social comparison theory. Communication Research, 42(4), 503–525. https://doi.org/10.1177/0093650214534969

Condon, E. M., Barcelona, V., Ibrahim, B. B., Crusto, C. A., & Taylor, J. Y. (2022). Racial discrimination, mental health, and parenting among African American mothers of preschool-aged children. Journal of the American Academy of Child & Adolescent Psychiatry, 61(3), 402–412. https://doi.org/10.1016/j.jaac.2021.05.023

Creswell, J. W., & Báez, J. C. (2020). 30 essential skills for the qualitative researcher. SAGE.

Currie, J. L. (2018). Managing motherhood: A new wellness perspective. Springer.

Davenport, M. H., Meyer, S., Meah, V. L., Strynadka, M. C., & Khurana, R. (2020). Moms are not ok: COVID-19 and maternal mental health. Frontiers in Global Women’s Health, 1. https://doi.org/10.3389/fgwh.2020.00001

Elliott, S., Powell, R., & Brenton, J. (2015). Being a good mom: Low-income, Black single mothers negotiate intensive mothering. Journal of Family Issues, 36(3), 351–370. https://doi.org/10.1177/0192513X13490279

Ferrari, M., Hunt, C., Harrysunker, A., Abbott, M. J., Beath, A. P., & Einstein, D. A. (2019). Self-compassion interventions and psychosocial outcomes: A meta-analysis of RCTs. Mindfulness, 10(8), 1455–1473.
https://doi.org/10.1007/s12671-019-01134-6

Fonseca, A., & Canavarro, M. C. (2018). Exploring the paths between dysfunctional attitudes towards motherhood and postpartum depressive symptoms: The moderating role of self-compassion. Clinical Psychology & Psychotherapy, 25(1), e96–e106. https://doi.org/10.1002/cpp.2145

Forbes, L. K., Donovan, C., & Lamar, M. R. (2020). Differences in intensive parenting attitudes and gender norms among U.S. mothers. The Family Journal, 28(1), 63–71. https://doi.org/10.1177/1066480719893964

Forbes, L. K., Lamar, M. R., & Bornstein, R. S. (2021). Working mothers’ experiences in an intensive mothering culture: A phenomenological qualitative study. Journal of Feminist Family Therapy, 33(3), 270–294.
https://doi.org/10.1080/08952833.2020.1798200

Germer, C. K., & Neff, K. (2019). Teaching the mindful self-compassion program: A guide for professionals. Guilford.

Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6–41. https://doi.org/10.1111/bjc.12043

Griffin, A., & May, V. (2012). Narrative analysis and interpretative phenomenological analysis. In C. Seale (Ed.), Researching society and culture (3rd ed., pp. 441–458). SAGE.

Grose, J. (2021, February 4). America’s mothers are in crisis. The New York Times. https://www.nytimes.com/spotlight/working-moms-coronavirus

Han, A., & Kim, T. H. (2023). Effects of self-compassion interventions on reducing depressive symptoms, anxiety, and stress: A meta-analysis. Mindfulness, 14, 1553–1581. https://doi.org/10.1007/s12671-023-02148-x

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. https://doi.org/10.1016/j.brat.2005.06.006

Hays, S. (1996). The cultural contradictions of motherhood. Yale University Press.

Hupkau, C., & Petrongolo, B. (2020). Work, care and gender during the COVID-19 crisis. Fiscal Studies, 41(3), 623–651. https://doi.org/10.1111/1475-5890.12245

Lamar, M. R., Forbes, L. K., & Capasso, L. A. (2019). Helping working mothers face the challenges of an intensive mothering culture. Journal of Mental Health Counseling, 41(3), 203–220. https://doi.org/10.17744/mehc.41.3.02

Lankes, J. (2022). Negotiating “impossible” ideals: Latent classes of intensive mothering in the United States. Gender & Society, 36(5), 677–703. https://doi.org/10.1177/08912432221114873

Larkin, M., & Thompson, A. R. (2011). Interpretative phenomenological analysis in mental health and psychotherapy research. In D. Harper & A. R. Thompson (Eds.), Qualitative research methods in mental health and psychotherapy: A guide for students and practitioners (pp. 99–116). Wiley.

Lathren, C., Bluth, K., & Zvara, B. (2020). Parent self-compassion and supportive responses to child difficult emotion: An intergenerational theoretical model rooted in attachment. Journal of Family Theory & Review, 12(3), 368–381. https://doi.org/10.1111/jftr.12388

Linehan, M. M. (2014). DBT® skills training manual. Guilford.

Lofton, O., Petrosky-Nadeau, N., & Seitelman, L. (2021). Parents in a pandemic labor market (Working Paper No. 2021-04). Federal Reserve Bank of San Francisco. https://doi.org/10.24148/wp2021-04

Mitchell, A. E., Whittingham, K., Steindl, S., & Kirby, J. (2018). Feasibility and acceptability of a brief online self-compassion intervention for mothers of infants. Archives of Women’s Mental Health, 21, 553–561.
https://doi.org/10.1007/s00737-018-0829-y

Moreira, H., Gouveia, M. J., Carona, C., Silva, N., & Canavarro, M. C. (2015). Maternal attachment and children’s quality of life: The mediating role of self-compassion and parenting stress. Journal of Child and Family Studies, 24, 2332–2344. https://doi.org/10.1007/s10826-014-0036-z

Myers, J. E., & Sweeney, T. J. (2004). The indivisible self: An evidence-based model of wellness. Journal of Individual Psychology, 60(3), 234–245. https://core.ac.uk/download/pdf/149232976.pdf

Neff, K. (2011). Self-compassion: The proven power of being kind to yourself. HarperCollins.

Neff, K. D., & Dahm, K. A. (2015). Self-compassion: What it is, what it does, and how it relates to mindfulness. In B. D. Ostafin, M. D. Robinson, & B. P. Meier (Eds.), Handbook of mindfulness and self-regulation (pp. 121–137). Springer. https://doi.org/10.1007/978-1-4939-2263-5_10

Neff, K. D., & Germer, C. K. (2013). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of Clinical Psychology, 69(1), 28–44. https://doi.org/10.1002/jclp.21923

Neff, K., & Germer, C. (2018). The mindful self-compassion workbook: A proven way to accept yourself, build inner strength, and thrive. Guilford.

Orenstein, G. A. & Lewis, L. (2021). Erikson’s stages of psychosocial development. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556096

Park, J. (2021). Who is hardest hit by a pandemic? Racial disparities in COVID-19 hardship in the U.S. International Journal of Urban Sciences, 25(2), 149–177. https://doi.org/10.1080/12265934.2021.1877566

Prikhidko, A., & Swank, J. M. (2018). Motherhood experiences and expectations: A qualitative exploration of mothers of toddlers. The Family Journal, 26(3), 278–284. https://doi.org/10.1177/1066480718795116

Psychogiou, L., Legge, K., Parry, E., Mann, J., Nath, S., Ford, T., & Kuyken, W. (2016). Self-compassion and parenting in mothers and fathers with depression. Mindfulness, 7, 896–908.
https://doi.org/10.1007/s12671-016-0528-6

Ruppanner, L., Tan, X., Carson, A., & Ratcliff, S. (2021). Emotional and financial health during COVID-19: The role of housework, employment and childcare in Australia and the United States. Gender, Work, & Organization, 28(5), 1937–1955. https://doi.org/10.1111/gwao.12727

Sackett, C. R., & Jenkins, A. M. (2015). Photovoice: Fulfilling the call for advocacy in the counseling field. Journal of Creativity in Mental Health, 10(3), 376–385. https://doi.org/10.1080/15401383.2015.1025173

Segal, Z., Williams, M., & Teasdale, J. (2018). Mindfulness-based cognitive therapy for depression (2nd ed). Guilford.

Smith, L., Davis, K., & Bhowmik, M. (2010). Youth participatory action research groups as school counseling interventions. Professional School Counseling, 14(2), 174–182. http://www.jstor.org/stable/42732946

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin.

Wang, C. C. (1999). Photovoice: A participatory action research strategy applied to women’s health. Journal of Women’s Health, 8(2), 185–192. https://doi.org/10.1089/jwh.1999.8.185

Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24(3), 369–387. https://doi.org/10.1177/109019819702400309

Wester, K. L., Wachter Morris, C. A., Trustey, C. E., Cory, J. S., & Grossman, L. M. (2021). Promoting rigorous research using innovative qualitative approaches. Journal of Counseling & Development, 99(2), 189–199. https://doi.org/10.1002/jcad.12366

Wilson, N., Dasho, S., Martin, A. C., Wallerstein, N., Wang, C. C., & Minkler, M. (2007). Engaging young adolescents in social action through photovoice: The Youth Empowerment Strategies (YES!) Project. The Journal of Early Adolescence, 27(2), 241–261. https://doi.org/10.1177/0272431606294834

World Health Organization. (2021, May). The true death toll of COVID-19: Estimating global excess mortality.
https://www.who.int/data/stories/the-true-death-toll-of-covid-19-estimating-global-excess-mortality

Zamarro, G., Perez-Arce, F., & Jose Prados, M. (2020). Gender differences in the impact of COVID-19. Center for Economic and Social Research, University of Southern California. https://www.ktla.com/wp-content/uploads/sites/4/2020/06/ZamarroGenderDiffImpactCOVID-19_061820-2.pdf

Kelly Emelianchik-Key, PhD, NCC, ACS, LMFT, LMHC-QS, is an associate professor at Florida Atlantic University. Adriana C. Labarta, PhD, NCC, ACS, LMHC, is an assistant professor at Florida Atlantic University. Clara Bossie, MS, ACS, LMFT-QS, is a doctoral candidate at Florida Atlantic University and Owner and Clinical Director of Wisely Wellness LLC. Carman S. Gill, NCC, ACS, LCMHC, is a professor and department chair at Florida Atlantic University. Correspondence may be addressed to Kelly Emelianchik-Key, Department of Counselor Education, Florida Atlantic University, 777 Glades Rd. Bldg. 47, Rm. 275, Boca Raton, FL 33431-0991, Kemelian@fau.edu.

Global Compassion Fatigue: A New Perspective in Counselor Wellness

Ariann Evans Robino

 

Explanations of compassion fatigue generally consider the client–counselor relationship as the primary source of challenges to wellness. Because of the nature of the current sociopolitical climate and the increased exposure through media, the counseling profession should consider expanding the influences on compassion fatigue related to current events. This article introduces the concept of global compassion fatigue (GCF), a phenomenon that provides an opportunity for counselor self-awareness. Implications for adopting GCF into the counselor impairment literature include understanding how global events impact counselor development and clinical practice as well as the importance of maintaining a wellness lifestyle to protect against its effects. Counselors’ involvement in advocacy and social justice are also explored as contributors to GCF.

 

Keywords: global compassion fatigue, counselor impairment, advocacy, self-awareness, wellness

 

 

Counselors and counselors-in-training (CITs) feel the weight of societal stressors. According to the ACA Code of Ethics, “promoting social justice” (American Counseling Association [ACA], 2014, p. 3) is a core value of the counseling profession. Furthermore, because of its impact on the profession, scholars have declared social justice as the fifth force in counseling (Ratts, 2009; Ratts, D’Andrea, & Arredondo, 2004). Representatives from ACA have acted in accordance by addressing the federal government’s recent prohibition of specific language associated with diverse populations (Yep, 2017) as well as releasing a statement of support shortly after the 2016 presidential election calling on all counselors to remain strong in their beliefs and actively assist those in need (Roland, 2016). Similarly, the closing keynote speaker at ACA’s Illuminate Symposium on June 10, 2017, Dr. Cheryl Holcomb-McCoy, encouraged attendees to take action against human rights offenses through vocal opposition in multiple settings, including social media (Meyers, 2017). These positions demonstrate the desired role of counselors to engage in advocacy and activism for global issues.

 

Natural disasters, threats to civil rights, violence, terrorist attacks, and animal welfare concerns are simply a few of the powerful issues that humans face as highly social and emotional beings. Although advocacy is one avenue of handling the emotional unrest related to these events, the complex nature of counselors’ personal and professional identities presents an invitation to consider these sensitive issues currently faced by society. Professional counselor identity allows counselors to make meaning of their work during these times of strong emotion (Solomon, 2007). Considering how these events affect both counselors’ and CITs’ personal lives and clinical practice produces opportunities for counselor professional development and greater self-awareness. The purpose of this article is to explore global compassion fatigue (GCF), a phenomenon related to the human condition and how global events impact professional counselors and other helpers. This article begins with a review of current counselor impairment concepts as well as the role of wellness in managing these conditions. Then, the reader is introduced to GCF and how a review of the literature supports the examination of this new concept. Next, I provide a detailed conceptualization of the phenomenon and implications for the field. Finally, suggestions for future research are provided.

 

Understanding Compassion Fatigue

 

Compassion fatigue research spans the literature of multiple disciplines, including nursing, social work, and counseling (Compton, Todd, & Schoenberg, 2017; Lynch & Lobo, 2012; Sorenson, Bolick, Wright, & Hamilton, 2016). Counselors typically understand compassion fatigue as an event occurring as a result of counselor–client interaction. Charles Figley (1995) first defined the concept of compassion fatigue as “a state of exhaustion and dysfunction—biologically, psychologically, and socially—a result of prolonged exposure to companion stress and all that it evokes” (p. 253) and conceptualized it as a response to the emotional demands of hearing and witnessing stories of pain and suffering. Symptoms of compassion fatigue include re-experiencing the client’s traumatic event, avoidance of reminders of the event and/or feeling numb to those reminders, and persistent arousal (Figley, 1995). Researchers carefully note the differences between compassion fatigue, vicarious traumatization, and burnout (Lawson & Venart, 2005; Meadors, Lamson, Swanson, White, & Sira, 2010). Vicarious traumatization, defined as a significant altering of cognitive schemas and a disruption of an individual’s sense of identity, worldview, and meaning, occurs as a result of empathic engagement with the traumatic experiences of a client (McCann & Pearlman, 1990). Vicarious traumatization symptoms involve a more covert change in thought and cognitive schema rather than an observable experiencing of symptomatology (Jenkins & Baird, 2002). Burnout is a process that occurs because of occupational stressors such as high caseloads, low morale, and minimal support (Maslach & Jackson, 1981). It is associated with emotional exhaustion, strain, and overload in addition to a reduction in personal accomplishment and job satisfaction (Maslach, 1982). Counselors are more likely to experience compassion fatigue, vicarious traumatization, and burnout when they have a previous history of personal trauma (Baird & Kracen, 2006), high emotional involvement with clients (Adams, Boscarino, & Figley, 2006), fewer perceived coping mechanisms (Baird & Kracen, 2006), and lower self-awareness (P. Clark, 2009). However, the goal of this article is to expand upon the phenomenon of compassion fatigue as distinguished from these other explanations of impairment to understand better how global events outside of the counselor–client dyad impact counselors. Although other impairment concepts hold value and applicability to counselors, compassion fatigue and its relationship to emotional suffering as a result of a desire to help others most closely aligns with the concept presented in this article. When considered in the context of counselors, an awareness of compassion fatigue, its effects, and how to mitigate those effects is vital for client welfare.

 

Counselor Impairment and Wellness

 

According to the ACA Code of Ethics, counselors should “monitor themselves for signs of impairment from their own physical, mental, or emotional problems” (ACA, 2014, p. 9). The ACA Code of Ethics dedicates an entire section to counselor impairment (C.2.g.), which states that, in the interest of client protection, counselors should cease providing services while impaired, seek assistance to solve issues of impairment, and assist colleagues and supervisors in recognizing and rectifying their own impairment (ACA, 2014). When counselors are impaired, it can result in significant harm to clients through an interference with the counseling process, trust violations, and ethical breaches (Lawson, Venart, Hazler, & Kottler, 2007). Adopting an alternative lens for viewing the impairment literature presents an opportunity for counselors to monitor themselves and others for potential issues as indicated by the ACA Code of Ethics (ACA, 2014). In addition, the ACA Code of Ethics guides counselors to “engage in self-care activities to maintain and promote their own emotional, physical, mental, and spiritual well-being to meet their professional responsibilities” (ACA, 2014, p. 8). As self-advocacy for wellness can promote better professional practice within the counseling community (Dang & Sangganjanavanich, 2015), counselors are encouraged to avoid and rectify issues of impairment through positive, health-promoting strategies.

 

Recognizing this area of need within the profession, ACA established the Taskforce on Counselor Wellness and Impairment in 2003 to address the needs of impaired counselors (Lawson & Venart, 2005). The taskforce identified goals for education for counselors on impairment and how to prevent it, securing treatment for impaired counselors, teaching self-care strategies, and advocating within the organization and at both the state and national levels to address issues associated with impairment. Although the taskforce focused on the broader topic of impairment, compassion fatigue remains a component of this experience. The creation, cultivation, and maintenance of a wellness lifestyle is a primary means of addressing and rectifying counselor impairment and compassion fatigue (Lawson & Venart, 2005).

 

Wellness is defined as “a way of life oriented toward optimal health and well-being in which body, mind, and spirit are integrated by the individual to live life more fully” (Myers, Sweeney, & Witmer, 2000, p. 252). Wellness and prevention are core components of counselors’ professional identities (Mellin, Hunt, & Nichols, 2011). As a result, researchers have studied the benefits of wellness strategies for counselors (Cummins, Massey, & Jones, 2007), counselor educators (Wester, Trepal, & Myers, 2009), and CITs (Yager & Tovar-Blank, 2007). Additionally, Figley (1995) specifically identified poor self-care as a primary risk factor for experiencing compassion fatigue, and Chi Sigma Iota’s (CSI; n.d.) advocacy themes, specifically Theme 6, outline the need for advocacy related to prevention and wellness for clients and counselors (Lee, 2012). The development of a taskforce, the extensive literature associated with compassion fatigue and wellness, and CSI’s identification of wellness as an area of advocacy indicate a clear relationship between counselor experience and counselor practice. Based on previous research, ACA’s stance on counselor self-care, and humans’ innate desire to engage in complex processes to achieve optimal functioning and well-being, it is beneficial for counselors to consider a new phenomenon related to their consistent exposure to global issues through media and social media. Counselors currently conceptualize compassion fatigue as a linear process occurring as a result of the cumulative direct exposure to clients’ distressing experiences. This article presents an expanded perspective on counselor compassion fatigue occurring as a result of exposure to current events and issues. Furthermore, this article offers a language for this experience as well as a conceptualization of the phenomenon.

 

GCF

     I suggest the term global compassion fatigue to describe the process by which an individual experiences extreme preoccupation and tension as a result of concern for those affected by global events without direct exposure to their traumas through clinical intervention. GCF requires examining compassion fatigue outside of client-specific experiences and within a larger context. This invites counselors and CITs to explore how they are human and existing in a conflicted, polarized, and oftentimes troubling world.

 

Figure 1 provides a visual depiction of these constructs. After exposure to a traumatic global event, humans experience an acute stress-related psychological response (Holman, Garfin, & Silver, 2013); for counselors this may manifest as GCF because of their foundational helping skills rooted in the ability to feel and exhibit empathy for the issues faced by others (A. J. Clark, 2010). Once this response occurs, counselors can utilize wellness and self-care strategies and engage in social justice advocacy efforts as deterrents to GCF. If they bypass these methods, they might experience the extreme preoccupation and tension that are indicators of GCF. However, counselors can interrupt and manage their GCF by moving to wellness and advocacy strategies.

 

Figure 1. Process of GCF. After media exposure to a global event and engaging in an emotional response, counselors can immediately experience GCF. Wellness and advocacy are two methods of either addressing GCF after experiencing it or through prevention to deter the experience.

 

 

 

GCF differs from vicarious traumatization in that it does not denote permanent change in cognitive schema; rather, a counselor can experience GCF transiently and in response to significant global and communal events. Counselors experiencing GCF do so outside of clients’ presenting problems. Although no current counseling literature describes this phenomenon, Stebnicki (2007) proposed the concept of empathy fatigue, which “results from a state of emotional, mental, physical, and occupational exhaustion that occurs as the counselors’ own wounds are continually revisited by their clients’ life stories of chronic illness, disability, trauma, grief and loss” (p. 318). Whereas GCF does bear similarity to empathy fatigue, empathy fatigue remains related to an occurrence resulting from direct clinical exposure (Stebnicki, 2007), and GCF involves counselor introspection unrelated to session content. Relatedly, Bayne and Hays (2017) recently conducted a study to conceptualize the conditions of empathy within the counseling process. They developed an exploratory model of counselor empathy that acknowledges the multidimensionality of the empathic process, including the variables associated with counselor impairment. GCF proposes that counselors’ intense emotional experiences related to global concerns are associated with empathy and a desire to help those directly affected. Current events that may cause a counselor to experience GCF include politics, natural disasters, violence (including mass shootings), terrorist attacks, threats to human rights, and animal abuse.

 

Compassion fatigue research is the best point of reference when considering the experience of GCF. Compassion fatigue manifests through physical, psychological, spiritual, and social symptoms (Lynch & Lobo, 2012), and counselors experiencing GCF also can exhibit these symptoms. However, counselors must consider the source of their feelings of fatigue. For example, Coetzee and Klopper (2010) noted, “compassion fatigue is caused by the prolonged, intense, and continuous care of patients, use of self, and exposure to stress” (p. 239). I suggest that GCF involves a similar experience, although as a result of continuous concern for other beings, a desire to help recover from or solve the issues affecting those beings, and repeated exposure to current events harming individuals on a large scale. Additionally, ACA’s Advocacy Competencies call for professional counselors to engage in systemic and sociopolitical advocacy on a continuum ranging from the microlevel (i.e., the individual) to the macrolevel (i.e., the public; Lewis, Arnold, House, & Toporek, 2003). Therefore, it is a counselor’s duty to remain aware of systemic, environmental, and political factors impacting clients in addition to immersing themselves in advocacy and mechanisms for change. Such actions may leave counselors susceptible to impairment in response to global issues, although moving from awareness to action also can help prevent or mitigate GCF.

 

Researchers have explored the effects of distressing events on helping professionals. Early research described the relationship between clergy members’ compassion fatigue and their time spent with trauma victims following the September 11th terrorist attacks (Flannelly, Roberts, & Weaver, 2005). Counselors responding after a natural disaster (Lambert & Lawson, 2013) and trauma counselors (Sansbury, Graves, & Scott, 2015) are populations often researched in the compassion fatigue literature. For example, Day, Lawson, and Burge (2017) reported the results of a qualitative research study exploring compassion fatigue and shared trauma in clinicians providing services after the shootings at Virginia Tech in 2007. Day et al. raised an interesting point between a counselor’s direct and indirect exposure to global events as well as the level of impairment resulting from the experience. Given the possibility that unresolved trauma can cause issues in functioning, direct exposure to an event removes the possibility that a counselor is experiencing GCF. This shared trauma may result in similar symptomatology, but these symptoms are attributed to the commonality of the trauma experience (Figley Institute, 2012).

 

From a different framework, researchers have explored the experiences of non-counselors when exposed indirectly to traumatic global events. Although many Americans were not in New York at the time of the September 11th attacks, nor were they likely to have known someone associated with the attacks, the stress of the event was felt across the country in the form of trauma symptoms (Schuster et al., 2001). Individuals living in Britain also experienced psychological changes as a result of the vicarious media exposure to these terror attacks on America (Linley, Joseph, Cooper, Harris, & Meyer, 2003). Similarly, college students at a separate university described an increase in acute stress symptoms as they learned about the shootings at Virginia Tech on television (Fallahi & Lesik, 2009). This research indicates that individuals can experience emotional duress in response to indirect exposure to global or national issues. Ultimately, it is important to remember that, despite extensive training and experience, counselors are humans navigating a society that can upset them in various ways. GCF awareness furthers counselor insight and promotes opportunities for evaluating self-care, wellness, and efficacy under these conditions. Such awareness requires an understanding of the role media plays in individuals’ experiencing of traumatic global events.

 

The Impact of Media

Previous researchers evaluated the impact of television viewing on an individual’s stress symptoms and levels of vicarious exposure (Fallahi & Lesik, 2009; Linley et al., 2003), suggesting that the role of technology can significantly affect a counselor’s ability to create boundaries and step away from the tragic circumstances occurring in the world around them. With 62% of adults obtaining their news from social media sites in 2016, an increase from 49% in 2012 (Gottfried & Shearer, 2016), it is clear that regular social media use can result in high levels of exposure to distressing news content. Additionally, four out of five adults in the United States reported constantly “checking” their cellular phones for emails, text messages, and social media (American Psychological Association, 2017). This same survey also described higher stress levels in the “constant checker” population than those using technology less frequently.

 

Researchers have discovered a link between emotional well-being and use of television media. Schlenger et al. (2002) found a statistically significant relationship between the levels of post-traumatic stress disorder symptoms and the numbers of hours spent watching television coverage of the September 11th terrorist attacks when assessing the psychological reactions of 2,273 adults residing in major metropolitan cities in the United States one to two months after the attacks. Fallahi and Lesik (2009) also identified a problematic association between indirect exposure to a tragic event through news media sources and symptoms of acute stress disorder.

 

Therefore, if a counselor or CIT is particularly sensitive to the content to which they are exposed through the media, they increase their risk of experiencing GCF. Conversely, social media also might provide an opportunity for community and connection in the face of global issues. The idea of community is no longer constrained within the bounds of physical associations; rather, the internet provides access to distant communities and relationships (Gruzd, Wellman, & Takhteyev, 2011). Supporters and activists involved in the Black Lives Matter movement are an example of such a community. Black Lives Matter erupted on social media as a Twitter hashtag created to raise awareness for and demonstrate protest against police brutality on members of the Black community (Petersen-Smith, 2015). Through this online movement, individuals were able to exhibit solidarity and take a stand against racism toward Black people with their use of social media (Schuschke & Tynes, 2016). Similarly, the #MeToo internet-based movement brought attention to women’s rights and sexual violence (Hostler & O’Neil, 2018), and social media platforms also provide a method of addressing the stigma of mental health and addiction (de la Cretaz, 2017).

 

ACA has an active social media presence through online pages and forums on their website, Facebook, Twitter, and LinkedIn (ACA, 2017). The ACA Code of Ethics (ACA, 2014) states that counselors will use social media only when it is in the best interest of the client while protecting their identity and well-being (Section H). This is another example in which a position is based on a situation specifically involving the client and counselor. Although researchers have explored the role of social media in counselor education (Tillman, Dinsmore, Chasek, & Hof, 2013) and recommendations have been made for using social media ethically in clinical practice (Giota & Kleftaras, 2014), researchers have yet to explore how social media affects practicing counselors on an emotional level. Adopting GCF into the counselor impairment literature would suggest a need for ACA to also establish recommendations for counselors’ social media use and how excessive exposure to global events can affect their work as counselors.

 

A New Perspective

As social beings dependent upon one another for survival, humans have an evolutionary and biological drive to feel connected and invested in others. Specifically, humans are interested in the welfare of others on a neurological level (Lieberman, 2013). Counselors and CITs can feel a need to help others based on evolutionary compulsions rooted in social psychology. However, they also can feel this drive to an amplified extent because of their consistent demonstration and use of empathy, a foundational helping skill that allows counselors to “enter the client’s phenomenal world, to experience the client’s world as it were your own without ever losing the ‘as if’ quality” (Rogers, 1961, p. 284). Although all humans are susceptible to experiencing fatigue as a result of high exposure to global issues through media, not all humans work in a helping profession based in the empathic experience. Therefore, similar to the need for counselors to monitor themselves for impairment as a result of direct engagement with clients’ presenting issues, counselors also need to monitor for impairment from global issues. Regardless of continuous exposure to distressing global events, counselors continue to help others on a consistent basis. This indicates a critical need for counselors to understand their relationship to social media and the global events to which they experience an emotional response.

 

Symptoms of GCF can manifest similarly to traditional compassion fatigue. These symptoms can include emotional and physical exhaustion associated with care for others, desensitization to stories and experiences, poorer quality of care, feelings of depression or anxiety, increased stress, difficulty concentrating, and preoccupation (Figley Institute, 2012). Ultimately, it is the responsibility of the counselor to understand the source of these symptoms. Unlike counselors’ direct work with clients in which there may be greater opportunities to assist in managing or addressing a pain-inducing problem, emotional and cognitive responses to global issues present a different type of challenge. Managing issues in which a person may perceive little control and direct influence can cause responses such as rumination (Nolen-Hoeksma, Wisco, & Lyubomirsky, 2008) and fear (Pain & Smith, 2008). Although counselors can experience these feelings regarding clients (Sansbury et al., 2015), there are greater opportunities for direct interaction with the client needing assistance. In most cases, counselors are unable to directly impact the people involved in the global events to which they are continuously exposed through media and social media. Optimal human functioning involves integration of the mind, body, and spirit (Myers et al., 2000). GCF can impact this integration when counselors are unable to live fully through the exhaustion of exposure to global events. Wellness strategies and forms of advocacy can prevent or rectify these experiences. Myers et al. (2000) acknowledged that “global events, whether of natural (e.g., floods, famines) or human (e.g., wars) origin, have an impact on the life forces and life tasks depicted in [wellness models]” (p. 252). In addition, advocacy in the wake of social events can provide feelings of efficacy and social connection (Scott & Maryman, 2016). This new perspective provides implications for the profession of counseling, including recommendations, cultural considerations, and areas of future research.

 

Implications for Counselors

 

In a “plugged-in” society, it is possible to become overwhelmed with the daily stream of news and information. Additionally, counselors can be at higher risk of experiencing impairment because of their empathic nature (Figley, 1995) and ethical duty to engage in social justice for causes that improve equity for individuals and groups (ACA, 2014). As leaders and advocates, GCF may be present in counselors’ daily clinical work. Licensed counselors in private practice may not be receiving ongoing supervision (Bernard & Goodyear; 2014); therefore, no external individual is monitoring how they are managing GCF and its effects. Counselors outside of supervision must exercise great care to practice self-awareness and approach others for assistance. Furthermore, counselors in high-volume settings often work with large caseloads that present with complex issues (Belling et al., 2011; Lombardo, 2018), and it may be easy for them to ignore their own needs while addressing the needs of others. Given the critical period of counselor development, GCF also must be considered within the context of counselor education. GCF during the formative period of graduate-level education in counseling can impede overall skill development. As new counselors find themselves more likely to experience compassion fatigue (Figley, 1995), the same may hold true for GCF. GCF may result in a type of developmental stalling in which counseling students feel an “empathy overload.” Such an overload of empathic emotions may impede the student’s transformation into a counselor. This provides implications for counselor education programs to measure students’ responses to emotionally distressing stimuli (O’Brien & Haaga, 2015) of both clinical and global nature as well as openly and unashamedly discuss signs and symptoms of impairment (Merriman, 2015).

 

I propose that counselors can manage GCF similarly to compassion fatigue because of the possibility of the two phenomena appearing symptomatically similar. However, GCF requires a greater level of self-awareness, recognition, and acceptance in order to address it. Counselors must learn how to distinguish between the two concepts and understand the possibility for overlap. A number of tools used to manage compassion fatigue can be used for GCF. Supervision, personal counseling, and consultation are all avenues of accountability, monitoring, and fidelity to the profession (Bernard & Goodyear, 2014). Although advocacy can be another tangible method of preventing or mitigating GCF, activism can cause emotional, mental, and physical exhaustion (Chen & Gorski, 2015); therefore, advocacy paired with careful attention to wellness can allow counselors to be most effective in helping to address global issues (Roysircar, 2009). Self-care practices and a wellness lifestyle may also act as protective factors to GCF. Myers et al. (2000) noted, “If one’s spirituality is healthy . . . [it] provides a firm foundation and core for the rest of the components of wellness” (p. 258). This indicates counselors developing an optimistic outlook in response to global events creates greater buffering or management of GCF. Similarly, these authors also state that self-direction allows a person to “move smoothly through time and space”
(p. 258). The cumulative pressure of global stressors necessitates firm self-direction to maintain focus in the chaos of present time and space. Wellness is cumulative and enhances longevity for professional practice (Myers et al., 2000). Ultimately, counselors are ethically responsible for ensuring they practice healthy boundaries and work within their competencies (ACA, 2014). An open dialogue with colleagues, self-awareness of strong responses to global events, pursuing systemic change through advocacy, and cultivating personal wellness encourage management of GCF (Robino & Pignato, 2017).

 

GCF holds particular relevance for counselors of color. Individuals from historically marginalized populations must understand, identify, and address their experiences and the effects of systemic and individualized racism as well as the psychological trauma of oppression and marginalization (Carter, 2007). The number of publicized events that occur in relation to civil rights issues and social justice concerns warrant additional consideration of GCF in specific populations. For example, police brutality against Black males can cause GCF in many counselors, particularly in counselors of color because of the negative psychological health outcomes for communities of color that stem from racism and discrimination (Carter & Forsyth, 2009; Comas-Díaz, 2016). Furthermore, violence (e.g., the Charleston, South Carolina, shooting targeting a specific religious group consisting of people of color and the Charlottesville, Virginia, protests that resulted in the death of a counter-protester) and localized natural disasters (e.g., fires in Tennessee and the Western United States that affected entire communities and hurricanes like Harvey, Irma, and Maria that caused devastation in the Southern United States and Puerto Rico) also increase the risk of GCF in counselors indirectly or somewhat directly exposed to these events. At the time of this writing, the president of the United States has signed an Immigration Executive Order (Executive Order No. 13,769, 2017) that calls for banning residents of certain Middle Eastern countries from entering the United States. In addition, the public expressed outrage at the removal of children from families seeking asylum at the U.S.–Mexico border (Goldstein, 2018). Such traumatic events become a systemic, multi-level public health issue (Magruder, McLaughlin, & Elmore Borbon, 2017) and increase the possibility of GCF among concerned individuals, including counselors and counseling students.

 

     The emergence of this concept paves the way for a broad range of research avenues. First, I recommend the study of GCF in counselor education programs. With CITs particularly sensitive to the nuances of the counseling profession (Bernard & Goodyear, 2014), the critical period of graduate education requires an examination into how GCF can affect counselor development. Second, the management of GCF calls for greater practice of self-care and exercising of insight. For example, researchers could explore the use of mindfulness and reflexivity in assessing how to treat counselors impacted by global events. Additionally, future research could explore the relationship of counselors’ social media use and GCF experiences. Statistics indicating the increase of social media as a news source (Gottfried & Shearer, 2016) raise questions of how counselors are impacted by their own internet activity. Researchers also could investigate counselor advocacy on social media. Although this article proposes that counselors may experience frustrations that contribute to GCF as a result of social media exposure to distressing global events, Dr. Holcomb-McCoy described social media as a tool for advocacy (Meyers, 2017), which may help in mitigating GCF. Such studies may assist counselors in delineating between GCF and other phenomena of impairment.

 

Finally, greater research is needed to assess and measure GCF. No accurate measurement yet exists for the phenomenon of GCF. Compassion fatigue measurements assess the negative aspects of helping others through direct contact (Figley, 1996). For GCF, this does not address the negative aspects of compassion for indirect exposure to global events. The Impact of Events Scale-Revised (IES-R; Weiss, 2007) measures the subjective distress associated with a traumatic event. However, the IES-R measures symptoms associated with post-traumatic stress disorder. Although it captures the experience of an external global event, it does not capture the transient, yet profound, emotional experience of GCF. The answer to assessing GCF may lie in the development of an instrument that combines compassion fatigue assessments and the IES-R to measure GCF symptoms as it relates to global events.

 

Conclusion

 

     This article introduces the concept of GCF into the counseling literature. By expanding the literature on other explanations of impairment, we broaden opportunities for self-awareness and professional development. Previously researched impairment concepts require an expansion into this new perspective by incorporating the effects of exposure to current events. This new phenomenon also contributes to counselor wellness research and the importance of maintaining a healthy wellness lifestyle as a deterrent to GCF. Adopting this concept and language into the literature on impairment and wellness encourages further consideration of counselor health, counselors’ management of distressing global events, and how this may impact both counselors and clients as humans.

 

As counselors become competent in their roles as advocates for social justice, their involvement in critical global events necessitates attention to the cumulative toll such a role may entail. In addition, consistent exposure to emotionally debilitating global events through social media places counselors in a peculiar position in which they must balance their need to remain informed of events and their need to remain healthy and well. Counselors carry the extra responsibility of remaining present and empathic with their clients while also protecting the empathy they experience for the world around them. Counselors’ marginalized and impacted cultural identities also factor into their experiences of GCF. In this regard, wellness becomes not simply an ethical duty, but also a professional imperative in the interest of both counselor and client welfare.

 

 

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.

 

 

 

References

 

Adams, R. E., Boscarino, J. A., & Figley, C. R. (2006). Compassion fatigue and psychological distress among social workers: A validation study. American Journal of Orthopsychiatry, 76, 103–108.
doi:10.1037/0002-9432.76.1.103

American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author.

American Counseling Association. (2017). Press room. Retrieved from https://www.counseling.org/about-us/about-aca/press-room

American Psychological Association. (2017). Stress in America: Coping with change. Retrieved from https://www.apa.org/news/press/releases/stress/2017/technology-social-media.pdf

Baird, K., & Kracen, A. C. (2006). Vicarious traumatization and secondary traumatic stress: A research synthesis. Counselling Psychology Quarterly, 19, 181–188. doi:10.1080/09515070600811899

Bayne, H. B., & Hays, D. G. (2017). Examining conditions for empathy in counseling: An exploratory model. The Journal of Humanistic Counseling, 56, 32–52. doi:10.1002/johc.12043

Belling, R., Whittock, M., McLaren, S., Burns, T., Catty, J., Jones, I. R., . . . the ECHO Group. (2011). Achieving continuity of care: Facilitators and barriers in community mental health teams. Implementation Science, 6, 23–29. doi:10.1186/1748-5908-6-23

Bernard, J. M., & Goodyear, R. K. (2014). Fundamentals of clinical supervision (5th ed.). Upper Saddle River, NJ: Pearson Education.

Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35, 13–105. doi:10.1177/0011000006292033

Carter, R. T., & Forsyth, J. M. (2009). A guide to the forensic assessment of race-based traumatic stress reactions. Journal of the American Academy of Psychiatry and the Law, 37, 28–40.

Chen, C. W., & Gorski, P. C. (2015). Burnout in social justice and human rights activists: Symptoms, causes, and implications. Journal of Human Rights Practice, 7, 366–390. doi:10.1093/jhuman/huv011

Chi Sigma Iota. (n.d.). Theme F: Prevention/wellness. Retrieved from http://www.csi-net.org/?Advocacy_Theme_F

Clark, A. J. (2010). Empathy: An integral model in the counseling process. Journal of Counseling & Development, 88, 348–356. doi:10.1002/j.1556-6678.2010.tb00032.x

Clark, P. (2009). Resiliency in the practicing marriage and family therapist. Journal of Marital and Family Therapy, 35, 231–247. doi:10.1111/j.1752-0606.2009.00108.x

Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A concept analysis. Nursing and Health Science, 12, 235–243. doi:10.1111/j.1442-2018.2010.00526.x

Comas-Díaz, L. (2016). Racial trauma recovery: A race-informed therapeutic approach to racial wounds. In A. N. Alvarez, C. T. H. Liang, & H. A. Neville (Eds.), The cost of racism for people of color: Contextualizing experiences of discrimination (pp. 249–272). Washington, DC: American Psychological Association.

Compton, L., Todd, S., & Schoenberg, C. (2017). Compassion fatigue and satisfaction among Critical Incident Stress Management (CISM) providers: A study on risk and mitigating factors. Virginia Counselors Journal, 35, 20–27.

Cummins, P. N., Massey, L., & Jones, A. (2007). Keeping ourselves well: Strategies for promoting and maintaining counselor wellness. Journal of Humanistic Counseling, Education, and Development, 46, 35–49. doi:10.1002/j.2161-1939.2007.tb00024.x

Dang, Y., & Sangganjanavanich, V. F. (2015). Promoting counselor professional and personal well-being through advocacy. Journal of Counselor Leadership and Advocacy, 2, 1–13. doi:10.1080/2326716X.2015.1007179

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

de la Cretaz, B. (2017, April 21). The Voices Project is fighting addiction & stigma through social media. Retrieved from https://www.thefix.com/voices-project-fighting-addiction-stigma-through-social-media

Exec. Order No. 13,769, 3 C.F.R. 8977-8982 (2017).

Fallahi, C. R., & Lesik, S. A. (2009). The effect of vicarious exposure to the recent massacre at Virginia Tech. Psychological Trauma: Theory, Research, Practice, and Policy, 1, 220–230. doi:10.1037/a0015052

Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Philadelphia, PA: Brunner/Mazel.

Figley, C. R. (1996). Review of the Compassion Fatigue Self-Test. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 127–130). Baltimore, MD: Sidran Press.

Figley Institute. (2012). Basics of compassion fatigue. Retrieved from http://www.figleyinstitute.com/documents/Workbook_AMEDD_SanAntonio_2012July20_RevAugust2013.pdf

Flannelly, K. J., Roberts, S. B., & Weaver, A. J. (2005). Correlates of compassion fatigue and burnout in chaplains and other clergy who responded to the September 11th attacks in New York City. Journal of Pastoral Care & Counseling, 59, 213–224. doi:10.1177/154230500505900304

Giota, K. G., & Kleftaras, G. (2014). Social media and counseling: Opportunities, risks, and ethical considerations. International Journal of Social, Behavioral, Educational, Economic, Business, and Industrial Engineering, 8, 2378–2380.

Goldstein, J. M. (2018, May 26). As ICE separates children from parents at the border, public outrage grows. Retrieved from https://thinkprogress.org/as-ice-separates-children-from-parents-at-the-border-public-outrage-grows-c624e69cd43f/

Gottfried, J., & Shearer, E. (2016, May 26). News use across social media platforms 2016. Retrieved from www.jour
nalism.org/2016/05/26/news-use-across-social-media-platforms-2016/

Gruzd, A., Wellman, B., & Takhteyev, Y. (2011). Imagining Twitter as an imagined community. American Behavioral Scientist, 55, 1294–1318. doi:10.1177/0002764211409378

Holman, E. A., Garfin, D. R., & Silver, R. C. (2013). Media’s role in broadcasting acute stress following the Boston Marathon bombings. Proceedings of the National Academy of Sciences, 111, 93–98.
doi:10.1073/pnas.1316265110

Hostler, M. J., & O’Neil, M. (2018, April 17). Reframing sexual violence: From #MeToo to Time’s Up. Stanford Social Innovation Review. Retrieved from https://ssir.org/articles/entry/reframing_sexual_violence_from_metoo_to_times_up

Jenkins, S. R., & Baird, S. (2002). Secondary traumatic stress and vicarious trauma: A validational study. Journal of Traumatic Stress, 15, 423–432. doi:10.1023/A:1020193526843

Lambert, S. F., & Lawson, G. (2013). Resilience of professional counselors following Hurricanes Katrina and Rita. Journal of Counseling & Development, 91, 261–268. doi:10.1002/j.1556-6676.2013.00094.x

Lawson, G., & Venart, B. (2005). Preventing counselor impairment: Vulnerability, wellness, and resilience. In VISTAS: Compelling perspectives on counseling. Retrieved from https://www.counseling.org/Resources/Library/VISTAS/
vistas05/Vistas05.art53.pdf

Lawson, G., Venart, E., Hazler, R. J., & Kottler, J. A. (2007). Toward a culture of counselor wellness. The Journal of Humanistic Counseling, Education, and Development, 46, 5–19. doi:10.1002/j.2161-1939.2007.tb00022.x

Lee, C. C. (2012). Social justice as the fifth force in counseling. In C. Y. Chang, C. A. Barrio Minton, A. L. Dixon, J. E. Myers, & T. J. Sweeney (Eds.), Professional counseling excellence through leadership and advocacy (pp. 109–120). New York, NY: Routledge/Taylor & Francis Group.

Lewis, J. A., Arnold, M. S., House, R., & Toporek, R. L. (2003). ACA advocacy competencies. Retrieved from https://www.counseling.org/resources/competencies/advocacy_competencies.pdf

Lieberman, M. D. (2013). Social: Why our brains are wired to connect. New York, NY: Crown.

Linley, P. A., Joseph, S., Cooper, R., Harris, S., & Meyer, C. (2003). Positive and negative changes following vicarious exposure to the September 11 terrorist attacks. Journal of Traumatic Stress, 16, 481–485. doi:10.1023/A:1025710528209

Lombardo, C. (2018, February 26). With hundreds of students, school counselors just try to ‘stay afloat’. Retrieved from https://www.npr.org/sections/ed/2018/02/26/587377711/with-hundreds-of-students-school-counselors-just-try-to-stay-afloat

Lynch, S. H., & Lobo, M. L. (2012). Compassion fatigue in family caregivers: A Wilsonian concept analysis. Journal of Advanced Nursing, 68, 2125–2134. doi:10.1111/j.1365-2648.2012.05985.x

Magruder, K. M., McLaughlin, K. A., & Elmore Borbon, D. L. (2017). Trauma is a public health issue. European Journal of Psychotraumatology, 81, 1375338. doi:10.1080/20008198.2017.1375338

Maslach, C. (1982). Burnout: The cost of caring. Englewood Cliffs, NJ: Prentice-Hall.

Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Occupational Behavior, 2(2), 99–113. doi:10.1002/job.4030020205

McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131–149.
doi:10.1007/BF00975140

Meadors, P., Lamson, A., Swanson, M., White, M., & Sira, N. (2010). Secondary traumatization in pediatric healthcare providers: Compassion fatigue, burnout, and secondary traumatic stress. OMEGA: Journal of Death and Dying, 60(2), 103–128. doi:10.2190/OM.60.2.a

Mellin, E. A., Hunt, B., & Nichols, L. M. (2011). Counselor professional identity: Findings and implications for counseling and interprofessional collaboration. Journal of Counseling & Development, 89, 140–147. doi:10.1002/j.1556-6678.2011.tb00071.x

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

Meyers, L. (2017, June 12). Illuminate closing: Less talk, more action. Counseling Today, Online Exclusives. Retrieved from https://ct.counseling.org/2017/06/illuminate-closing-less-talk-action/

Myers, J. E., Sweeney, T. J., & Witmer, J. M. (2000). The Wheel of Wellness counseling for wellness: A holistic
model for treatment planning. Journal of Counseling & Development, 78, 251–266.
doi:10.1002/j.1556-6676.2000.tb01906.x

Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3, 400–424. doi:10.1111/j.1745-6924.2008.00088.x

O’Brien, J. L., & Haaga, D. A. F. (2015). Empathic accuracy and compassion fatigue among therapist trainees. Professional Psychology: Research and Practice, 46, 414–420. doi:10.1037/pro0000037

Pain, R., & Smith, S. J. (Eds.). (2008). Fear: Critical geopolitics and everyday life. New York, NY: Routledge/Taylor & Francis Group.

Petersen-Smith, K. (2015). Black Lives Matter: A new movement takes shape. International Socialist Review, 96. Retrieved from http://isreview.org/issue/96/black-lives-matter

Ratts, M. J. (2009). Social justice counseling: Toward the development of a “fifth force” among counseling paradigms. The Journal of Humanistic Counseling, Education, and Development, 48(2), 160–172.
doi:10.1002/j.2161-1939.2009.tb00076.x

Ratts, M. J., D’Andrea, M., & Arredondo, P. (2004). Social justice counseling: “Fifth force” in the field. Counseling Today, 47, 28–30.

Robino, A., & Pignato, L. (2017, February). Global compassion fatigue: An ethical duty for awareness and action. Paper presented at the Virginia Association for Counselor Education and Supervision (VACES) Conference, Norfolk, VA.

Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston, MA: Houghton Mifflin.

Roland, C. B. (2016, November 10). ACA president issues post-election statement of support. Retrieved from https://www.counseling.org/news/updates/2016/11/10/aca-president-issues-post-election-statement-of-support

Roysircar, G. (2009). The big picture of advocacy: Counselor, heal society and thyself. Journal of Counseling & Development, 87, 288–294. doi:10.1002/j.1556-6678.2009.tb00109.x

Sansbury, B. S., Graves, K., & Scott, W. (2015). Managing traumatic stress responses among clinicians: Individual and organizational tools for self-care. Trauma, 17(2), 114–122. doi:10.1177/1460408614551978

Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., . . . Kulka, R. A. (2002). Psychological reactions to terrorist attacks: Findings from the national study of Americans’ reactions to September 11. JAMA: Journal of the American Medical Association, 288, 581–588. doi:10.1001/jama.288.5.581

Schuschke, J., & Tynes, B. M. (2016). Online community empowerment, emotional connection, and armed love in the Black Lives Matter Movement. In S. Y. Tettegah (Ed.), Emotions, technology, and social media (pp. 25–47). San Diego, CA: Academic Press.

Schuster, M. A., Stein, B. D., Jaycox, L. H., Collins, R. L., Marshall, G. N., Elliott, M. N., . . . Berry, S. H. (2001). A national survey of stress reactions after the September 11, 2001, terrorist attacks. The New England Journal of Medicine, 345, 1507–1512. doi:10.1056/NEJM200111153452024

Scott, J. T., & Maryman, J. (2016). Using social media as a tool to complement advocacy efforts. Global Journal of Community Psychology Practice, 7(1S), 1–22. doi:10.7728/0701201603

Solomon, J. (2007). Metaphors at work: Identity and meaning in professional life. Retrieved from http://thegoodproje
ct.org/pdf/JSolomon-Metaphors-at-Work-Manuscript-Nov-2007.pdf

Sorenson, C., Bolick, B., Wright, K., & Hamilton, R. (2016). Understanding compassion fatigue in healthcare providers: A review of current literature. Journal of Nursing Scholarship, 48, 456–465. doi:10.1111/jnu.12229

Stebnicki, M. A. (2007). Empathy fatigue: Healing the mind, body, and spirit of professional counselors. American Journal of Psychiatric Rehabilitation, 10, 317–338. doi:10.1080/15487760701680570

Tillman, D. R., Dinsmore, J. A., Chasek, C. L., & Hof, D. D. (2013). The use of social media in counselor education. In Ideas and Research you can use: VISTAS 2013. Retrieved from http://www.counseling.org/docs/default-source/vistas/the-use-of-social-media-in-counselor-education.pdf?sfvrsn=370433a5_10

Weiss, D. S. (2007). The Impact of Event Scale—Revised. Retrieved from http://www.emdrhap.org/co
ntent/wp-content/uploads/2014/07/VIII-E_Impact_of_Events_Scale_Revised.pdf

Wester, K. L., Trepal, H. C., & Myers, J. E. (2009). Wellness of counselor educators: An initial look. The Journal of Humanistic Counseling, Education, and Development, 48, 91–109. doi:10.1002/j.2161-1939.2009.tb00070.x

Yager, G. G., & Tovar-Blank, Z. G. (2007). Wellness and counselor education. The Journal of Humanistic Counseling, Education, and Development, 46(2), 142–153. doi:10.1002/j.2161-1939.2007.tb00032.x

Yep, R. (2017, December 21). ACA weighs in on wording restrictions at the Centers for Disease Control [Blog post]. Retrieved from https://www.counseling.org/news/aca-blogs/aca-government-affairs-blog/aca-government-affairs-blog/2017/12/20/aca-weighs-in-on-wording-restrictions-at-the-centers-for-disease-control

 

 

Ariann Evans Robino, NCC, is an assistant professor at Nova Southeastern University. Correspondence can be addressed to Ariann Robino, 3301 College Avenue, Maltz Building, Fort Lauderdale, FL 33314, arobino@nova.edu.

Individual and Relational Predictors of Compassion Fatigue Among Counselors-in-Training

Nesime Can, Joshua C. Watson

 

Scholars have described compassion fatigue as the result of chronic exposure to clients’ suffering and traumatic stories. Counselors can struggle when they experience compassion fatigue because of various reasons. As such, an exploration of factors predictive of compassion fatigue may help counselors and supervisors buffer adverse effects. Utilizing a hierarchical linear regression analysis, we examined the association between wellness, resilience, supervisory working alliance, empathy, and compassion fatigue among 86 counselors-in-training (CITs). The research findings revealed that resilience and wellness were significant predictors of compassion fatigue among CITs, whereas empathy and supervisory working alliance were not. Based on our findings, counselor educators might consider enhancing their current training programs by including discussion topics about wellness and resilience, while supervisors consider practicing wellness and resilience strategies in supervision and developing interventions designed to prevent compassion fatigue.

 

Keywords: compassion fatigue, counselors-in-training, wellness, resilience, supervisory working alliance

 

 

Balancing self-care and client care can be a challenge for many counselors. When counselors neglect self-care, they can become vulnerable to several issues, including increased anxiety, distress, burnout, and compassion fatigue (Ray, Wong, White, & Heaslip, 2013). Counselors might be especially prone to experiencing compassion fatigue because they repeatedly hear traumatic stories and clients’ suffering in sessions (Skovholt & Trotter-Mathison, 2016). This phenomenon is likely pronounced among counselors-in-training (CITs), as lack of experience, skillset, knowledge, and support can lead to struggles when working with clients (Skovholt & Trotter-Mathison, 2016). Coupled with the increased anxiety, distress, and disappointment, CITs can experience compassion fatigue early in their career development, which can lead to exhaustion, disengagement, and a decline in therapeutic effectiveness (Rønnestad & Skovholt, 2013). At this developmental stage, negative experiences can lead to feelings of doubt and a lack of confidence among CITs and potentially lead to career dissatisfaction. Therefore, it is essential and necessary to better understand the predictive factors of compassion fatigue among CITs to prevent its early onset.

 

Compassion Fatigue in Counseling

 

Counselors listening to their clients’ fear, pain, and suffering can feel similar emotions. Figley (1995) defined this experience as compassion fatigue; it also can be defined as the cost of caring (Figley, 2002). Whether working in mental health agencies, schools, or hospital settings, counselors experience compassion fatigue because of exposure to large caseloads, painful stories, and lack of support and resources (Skovholt & Trotter-Mathison, 2016). Despite this exposure, counselors are expected to place their personal feelings aside and provide the best treatment possible in response to the presenting issues and needs of their clients (Figley, 2002; Ray et al., 2013; Turgoose, Glover, Barker, & Maddox, 2017). Maintaining this sense of detached professionalism has its costs, as a number of counselors find themselves at risk for experiencing physical, mental, and emotional exhaustion, as well as feelings of helplessness, isolation, and confusion—a situation collectively referred to as compassion fatigue (Eastwood & Ecklund, 2008; Thompson, Amatea, & Thompson, 2014).

 

Merriman (2015b) stated that ongoing compassion fatigue negatively impacts counselors’ health as well as their relationships with others. Additionally, compassion fatigue can lead to a lack of empathy toward clients, decrease in motivation, and performance drop in effectiveness, making even the smallest tasks seem overwhelming (Merriman, 2015b). When this occurs, counselors can project their anger on others, develop trust issues, and experience feelings of loneliness (Harr, 2013). Therefore, the demands of the counseling profession can affect many counselors’ wellness and potentially could hurt the quality of client care provided (Lawson, Venart, Hazler, & Kottler, 2007; Merriman, 2015a). Further, counselors experiencing compassion fatigue might have difficulties making effective clinical decisions and potentially be at risk for harming clients (Eastwood & Ecklund, 2008). Consequently, scholars appear to agree that compassion fatigue is an occupational hazard that mental health care professionals need to address (Figley, 2002; Merriman, 2015a).

 

Factors Associated With Compassion Fatigue

 

Many researchers have studied the relationships between compassion fatigue and various constructs, such as empathy, gender, mindfulness, support, and wellness (e.g., Beaumont, Durkin, Martin, & Carson, 2016; Caringi et al., 2016; Ray et al., 2013; Sprang, Clark, & Whitt-Woosley, 2007; Turgoose et al., 2017). Researchers conducted most of these studies among novice and veteran mental health professionals. Scant research among CITs exists. Our research attempts to fill this gap by exploring factors affecting CITs given their unique position as both students and emerging professionals. The following review of the literature supports the inclusion of predictor variables used in this study.

 

Empathy and Compassion Fatigue

One of the most widely studied concepts across various cultures is empathy, as it has been determined to be one of the major precipitants of compassion fatigue (Figley, 1995). However, findings in the literature regarding the association between compassion fatigue and empathy remain mixed (e.g., MacRitchie & Leibowitz, 2010; O’Brien & Haaga, 2015; Wagaman, Geiger, Shockley, & Segal, 2015). For instance, O’Brien and Haaga (2015) compared trait empathy and empathic accuracy with compassion fatigue after showing a videotaped trauma self-disclosure among therapist trainees (a combined group of advanced and novice graduate students) and non-therapists. The results indicated that there was no significant association between participants’ levels of compassion fatigue and empathy scores. However, MacRitchie and Leibowitz (2010) found a significant relationship between compassion fatigue and empathy after exploring the relation of these variables on trauma workers whose clients were survivors of violent crimes. The mixed results of these previous studies suggest further research is needed to understand better the relationship between empathy and compassion fatigue and how this relationship impacts counseling practice.

 

Supervisory Working Alliance and Compassion Fatigue

Although reviewed literature addressed studies suggesting supervision and support are related factors to compassion fatigue, research on this relationship is still insufficient. Kapoulitsas and Corcoran (2015) conducted a study and found that a positive supervisory relationship has a significant role in developing resilience and reducing compassion fatigue among counselors. Knight (2010) also found that students uncomfortable talking with their supervisor reported a higher risk for developing compassion fatigue. Additionally, organizational support appears to reduce compassion fatigue, whereas an absence of support increases practitioners’ and interns’ risk of developing compassion fatigue symptoms (Bride, Jones, & MacMaster, 2007). Given the intense need for support and guidance CITs need during their initial work with clients, it is expected that those students who do not actively work with their supervisors can struggle and be more vulnerable for compassion fatigue.

 

Wellness, Resilience, and Compassion Fatigue

Although counselors are encouraged to practice self-care activities to continue to enhance personal well-being (American Counseling Association [ACA], 2014; Coaston, 2017; H. L. Smith, Robinson, & Young, 2008), not all CITs can balance caring for self and others. When CITs do not receive training in the protective factors for compassion fatigue, they risk becoming more vulnerable to violating the ACA code of ethics (Merriman, 2015a; Merriman, 2015b). Kapoulitsas and Corcoran (2015) and Skovholt and Trotter-Mathison (2016) highlighted the importance of resilience and self-care activities as protective factors for compassion fatigue. Wood et al. (2017) evaluated the effectiveness of a mobile application called Provider Resilience to reduce compassion fatigue scores of mental health professionals. After a month of utilization, the results indicated that the application was effective in reducing compassion fatigue. Additionally, Lawson and Myers (2011) conducted a study with professional counselors to examine counselor wellness about compassion fatigue and found a negative correlation between total wellness scores and compassion fatigue scores. As CITs balance academic, family, and work demands, the probability of decreased wellness and a corresponding increase in compassion fatigue exists.

 

Compassion Fatigue Among CITs

 

Most CITs are often unable to master all counselor competencies (Rønnestad & Skovholt, 2013), and therefore they might not know how to deal with possible stressors and the emotional burden of their work (Star, 2013). Although they are learning counseling skills to provide the best care possible to clients, CITs may find themselves working with seriously troubled or traumatized clients without obtaining quality supervision and support (Skovholt & Trotter-Mathison, 2016). Lack of skills and resources increases the likelihood of CITs developing compassion fatigue (Merriman, 2015b). However, there is a lack of focus in compassion fatigue education on preparing CITs to manage compassion fatigue symptoms (Merriman, 2015a). Although scholars have examined compassion fatigue among counselors, there is still a dearth of studies investigating the level of compassion fatigue among CITs and addressing its protective factors within this population (Beaumont et al., 2016; Blount, Bjornsen, & Moore, 2018; Thompson et al., 2014). Subsequently, further research is needed to understand better potential protective factors that can be enhanced to offset the negative impact of compassion fatigue on CITs and the counseling process. Thus, with this study, we aimed at assessing the relationship between resilience, wellness, supervisory working alliance, empathy, and compassion fatigue among CITs in the United States. To accomplish this goal, we sought to answer the following research questions: (1) What is the prevalence of compassion fatigue among CITs? and (2) Do empathy, supervisory working alliance, resilience, and wellness significantly predict levels of compassion fatigue among CITs?

 

Method

 

Participants

Participants recruited for this study consisted of master’s-level counseling students who are at least 18 years of age and enrolled in an internship course in the United States through mostly professional listservs (e.g., Counselor Education and Supervision Network Listserv [CESNET-L], Texas Association for Counselor Education and Supervision Network Listserv [TACESNET-L], Counseling Graduate Student Network [COUNSGRADS]). Because of the impossibility of knowing how many individuals received the email invitation, we were unable to calculate and determine a response rate. Accordingly, a total of 114 CITs initially agreed to participate in this study. Before data analysis, we inspected the data set for possible entry errors and missing data. After the inspection, we excluded 28 participants from all subsequent data analyses resulting in the reduced sample of 86 CITs used to address our research questions. Overall, the sample consisted of 78 female (90.7%) and eight male (9.3%) participants, and the mean age of the participants was 32.89 years (SD = 9.72) with participants’ ages ranging between 21 and 62 years. Participants were from diverse ethnic and racial backgrounds, with the sample consisting of White (n = 48, 55.8%), Hispanic/Latino (n = 18, 20.9%), Black/African American (n = 12, 14.0%), and Asian (n = 5, 5.8%) CITs. Three participants (3.5%) listed their ethnicities as “other” when providing demographic information. Participants reported their program enrollment as follows: clinical mental health counseling program (n = 47, 54.7%); school counseling program (n = 23, 26.7%); marriage, couple, and family counseling program (n = 4, 4.7%); college counseling and student affairs program (n = 3, 3.5%); addiction counseling program (n = 2, 2.3%); and other programs (n = 7, 8.1%). Additionally, most of the participants (n = 73, 84.9%) reported enrollment in a CACREP-accredited program with the remaining participants (n = 13, 15.1%) enrolled in a non–CACREP-accredited program.

 

Procedure

Upon receiving institutional review board approval, we recruited participants from different institutions with the primary researcher contacting professional colleagues at various departments to disseminate the online survey link to potential participants during the 2017 summer and fall semesters. We also recruited participants through professional listservs (e.g., CESNET-L, TACESNET-L, COUNSGRAD), with listserv participants being provided the same informed consent and survey link through a secure website. The survey completion process took approximately 15–20 minutes.

 

Measures

We used the following self-administered survey questionnaires and a separate demographic data sheet in our data collection.

 

     Professional Quality of Life Scale (ProQOL). This scale is designed to measure the mental and emotional consequences of working with individuals who experienced trauma or painful events (Stamm, 2010). The ProQOL includes two main traits, Compassion Satisfaction (positive) and Compassion Fatigue (negative). Compassion Satisfaction is related to the joy individuals develop when they do their work well (Stamm, 2010). Compassion Fatigue consists of two subscales: Secondary Traumatic Stress (STS) and Burnout. Scholars have defined STS as an emotional state that occurs when an individual becomes upset or traumatized as a result of their exposure to victim experiences (Figley, 2002). The second part of Compassion Fatigue is Burnout, which is a multidimensional syndrome related to the social work environment. Burnout could be related to work overload, lack of control, insufficient rewards, unfairness, and value conflict at a workplace (Skovholt & Trotter-Mathison, 2016).

 

The ProQOL is a 30-item Likert-type self-report assessment with responses of never, rarely, sometimes, often, and very often for each item. A sample item is “I feel depressed because of the traumatic experiences of the people I [help].” This assessment has 10 questions per each of three main scales measuring separate constructs. However, the Compassion Fatigue scale includes two of these constructs, which are the Burnout and the STS scales. According to Stamm (2010), the ProQOL has good construct validity, as researchers have noted its efficacy in over 200 published articles. Finally, alpha coefficient values for the Burnout and STS scales were .75 and .81, respectively (Stamm, 2010), and are similar (.72 and .79) to the Cronbach’s alpha values from the current study presented in Table 1.

 

Table 1

Descriptive Statistics of the Study Variables (N = 86)

Range
Variable M SD Min Max Skew α
Compassion Fatigue 41.48 8.03 22 60    .19
BO 21.34 4.38 12 32 .72
STS 20.14 4.96 10 38 .79
Empathy 21.86 4.12   9 28   -.51 .80
Supervisory Working Alliance   5.82   .97   2.16   7  1.26
CF   6.65 1.30   2.17   8.17 .90
R   5.80   .96   2.33   7 .93
Resilience   3.43   .79   1   4.67   -.74 .89
Wellness 47.58 6.23 27 56 -1.39 .86


Note. BO = Burnout; STS = Secondary Traumatic Stress; CF = Client Focus; R = Rapport

 

 

     Interpersonal Reactivity Index (IRI). Davis (1983) developed the IRI to measure the reactions of a person to other individuals’ observed experiences. The 28-item instrument has four subscales: Empathic Concern, Perspective Taking, Fantasy, and Personal Distress (Davis, 1983). Researchers report separate subscale scores, as a total score for the instrument has not been recommended (Davis, 1983). In this study, we only used the Empathic Concern subscale to collect data regarding empathy scores of CITs.

 

Davis (1983) described empathic concern as an emotional response, such as compassion and sympathy, to someone else in need. The 7-item subscale is a self-report assessment with a 5-point Likert-type scale, ranging from Does not describe me well to Describes me very well. A sample item is “I am often quite touched by things that I see happen.” An alpha coefficient of .77 has been reported for the Empathic Concern subscale (Péloquin & Lafontaine, 2010), while the Cronbach’s alpha value of the IRI in the current study was .80.

 

     Supervisory Working Alliance Inventory: Trainee Form (SWAI-T). Efstation, Patton, and Kardash (1990) developed this inventory to measure supervisees’ perceptions about the effectiveness of the working relationship with their supervisors, and we used the SWAI-T to measure the construct of the supervisory working alliance. With a total of 19 items, the self-report assessment includes a 7-point Likert-type scale with responses ranging from almost never to almost always. A sample item is “When correcting my errors with the client, my supervisor offers alternative ways of intervening with the client.” The SWAI-T has two subscales—Client Focus and Rapport—and the Cronbach alpha coefficients of these scales were .77 and .90, respectively (Efstation et al., 1990). For the current study, we calculated Cronbach alpha values of .90 for the Client Focus subscale and .93 for the Rapport subscale. Because some researchers have found high correlations between these two subscales, they decided to combine them in their studies (e.g., Ganske, 2007; White & Queener, 2003). Therefore, in this study, after conducting a correlation analysis with the subscale scores, we also chose to combine subscales as the results of subscale scores were highly correlated.

 

     Brief Resilience Scale (BRS). The BRS was developed to measure a person’s ability to recover from stress and cope with challenging situations (B. W. Smith et al., 2008). The BRS is used to measure the construct of resilience. As a 6-item self-report assessment, the BRS includes a 5-point Likert-type scale with responses ranging from strongly disagree to strongly agree. A sample item is “I usually come through difficult times with little trouble.” B. W. Smith and colleagues (2008) reported that the Cronbach’s alpha values of the BRS range from .80 to .91, and we calculated a Cronbach alpha of .89 for the current study.

 

     Flourishing Scale (FS). The FS was designed to measure individuals’ self-perceived success in areas like optimism and relationships (Diener et al., 2010) and used to measure the construct of wellness in this study. The FS is an 8-item self-report assessment with a 7-point Likert-type scale with responses ranging from strongly disagree to strongly agree (Diener et al., 2010). A sample item is “I lead a purposeful and meaningful life.” Diener and colleagues (2010) reported moderately high reliability with a .87 Cronbach’s alpha coefficient, and in the current study, the FS had a Cronbach alpha of .86.

 

Data Analysis

     Statistical power analysis. We used an a priori type of the G*Power to set the minimum number of participants needed to detect statistical power for this research design. Based on an alpha of .05, a power level of .90, and four predictors (Faul, Erdfelder, Buchner, & Lang, 2009), the computation results suggested that a minimum of 73 participants was required to detect statistical significance with at least a moderate size effect (.15). We had 86 participants, suggesting adequate power.

 

     Preliminary analyses. We analyzed all data using the Statistical Package for the Social Sciences, Version 20 (SPSS; IBM Corporation, 2011). Before addressing our stated research questions, we cleaned the dataset and addressed missing data. We did not observe any pattern between missing data points. Therefore, the type of missing data was completely random, which was addressed using the series of mean function within the SPSS. Next, we calculated descriptive statistics and alpha coefficients for each scale used in the study (see Table 1). Before performing hierarchical regression analyses, we tested all associated model assumptions. First, we examined study variables based on their types and concluded each utilized a continuous scale. We then assessed normality with the Shapiro-Wilk test of normality (W > .05), indicating data was normally distributed for the dependent variable. To identify outliers, we examined boxplots. Although there were a few mild outliers, no extreme scores were detected. We assessed linearity and homoscedasticity through inspection of standardized residual plots. To assess for the assumption of multicollinearity, we examined the correlation matrix of study variables to determine if any correlated highly. According to Field (2013), correlations above .80 are considered high and may indicate the presence of multicollinearity. In the present study, none of the correlation coefficients were above .50 (see Table 2). Collectively, these findings indicated no evidence suggesting any of the model assumptions had been violated. As a result, the dataset was deemed appropriate for analysis using a hierarchical regression design.

 

     Primary analysis. Descriptive statistics were calculated to organize the data by producing means, mode, median, standard deviations, and minimum and maximum scores for the study variables (Field, 2013). Individually, we reviewed descriptive statistics for the compassion fatigue variable, and results were reported to address the first research question. Next, we performed a three-step hierarchical linear regression to address the second research question.

 

Table 2

 

Intercorrelations for Scores on the Study Variables

Variable 1 2 3 4 5
1. ProQOL-CF
2. SWAIT-T   .04
3. IRI-EC  -.06  .04
4. BRS    -.47** -.09 -.11
5. FS    -.45**  .12    .25* .35**


Note. N = 86; ProQOL = Professional Quality of Life (Compassion Fatigue [CF] subscale score is presented); IRI = Interpersonal Reactivity Index (Empathic Concern [EC] subscale score is presented); SWAI-T = Supervisory Working Alliance Inventory: Trainee Form; BRS = Brief Resilience Scale; FS = Flourishing Scale.

*p < .05.  **p < .01.

 

 

 

Results

 

Compassion fatigue scores of CITs represent the sum of scores of all items on the STS and Burnout subscales. According to the ProQOL administration manual (Stamm, 2010), individuals scoring below 22 may indicate little or no issues with Burnout and STS, while scores between 23 and 41 indicate moderate levels of Burnout and STS, and scores above 42 indicate higher levels of Burnout and STS. For this sample, participants’ Burnout scores ranged from 12 to 32 with a mean of 21.34 (SD = 4.38), and STS scores ranged from 10 to 38 with a mean of 20.14 (SD = 4.96). These results indicated a low risk of both Burnout and STS among CITs.

 

To address the second research question, we performed a three-step hierarchical linear regression analysis. With this analysis, we aimed to assess the association between resilience, wellness, supervisory working alliance, empathy, and compassion fatigue. We chose to implement a hierarchical multiple regression analysis because scholars previously have highlighted the essential relationship between empathy, supervision, and compassion fatigue (Figley, 2002; MacRitchie & Leibowitz, 2010). In the first step, empathy scores entered the model as a predictor variable, as Figley (1995) stated that empathy is one of the main factors contributing to compassion fatigue. However, among this sample, we found that empathy was not a significant predictor of compassion fatigue: F(1, 84) = .2, p = .66 , R2 = .002 (adjusted R2 = -.01). Then, we added supervisory working alliance scores to the model in the second step, as both Knight (2010) and Miller and Sprang (2017) emphasized the importance of supervisory support for mental health practitioners. Results revealed that the supervisory working alliance variable also was not a significant predictor of compassion fatigue: F(2, 83) = .16, p = .85, R2 = .004 (adjusted R2 = -.02). In the third step, resilience and wellness scores were entered into the model to determine whether these variables significantly improved the amount of explained variance in compassion fatigue. Results showed that this combination of variables significantly predicted 26% of the variance in compassion fatigue: F(4, 81) = 8.57, p < .001, R2 = .30. Therefore, it was concluded that CITs with greater wellness and resilience reported developing less compassion fatigue (see Table 3).

 

Table 3

Hierarchical Regression Analysis Results for Variables Predicting Compassion Fatigue

Variables B SEB β R2 ΔR2
Step 1 .002 -.01
Empathy   -.09 .21 -.05
Step 2 .004 -.02
Empathy   -.10 .21 -.05
SWA    .33 .91  .04
Step 3 .30*  .26
Empathy   -.03 .19 -.02
SWA    .36 .78  .04
Wellness   -.39 .14  -.30*
Resilience  -3.66     1.05  -.36*


Note. SWA = Supervisory Working Alliance

*p < .05.

 

 

Discussion

 

In this study, CITs reported having a low risk of compassion fatigue. When we examined the Burnout and STS scores separately, the main contributors of compassion fatigue (Stamm, 2010), both subscale scores indicated participants having a low risk for STS and Burnout. This finding is similar to results found by Beaumont and colleagues (2016) in their study of compassion fatigue, burnout, self-compassion, and well-being relationships among student counselors and student cognitive behavioral psychotherapists. According to their research findings, a total of 54 student participants reported high scores on self-compassion and well-being and reported less compassion fatigue and burnout (Beaumont et al., 2016).

 

One of the goals of this study was to seek understanding of whether wellness and resilience explain a statistically significant amount of variance in compassion fatigue among CITs after accounting for empathy and supervisory working alliance. The results indicated that empathy and supervisory working alliance were not significant predictors of compassion fatigue. Regarding empathy and compassion fatigue relation results, the findings of this study did not support Figley’s (1995) assumption of empathy as one of the main contributors to compassion fatigue. This result also is inconsistent with Wagaman and colleagues’ (2015) results indicating a significant association between empathy and compassion fatigue among social workers. However, current results aligned with those studies that found no correlation between empathy and compassion fatigue (e.g., O’Brien & Haaga, 2015; Thomas & Otis, 2010). An explanation of the variability between this inquiry and previous studies might lie with the difference between participants’ field of study and measurement differences. Also, none of the previous studies used CITs solely as their sample, nor used a similar way to measure the construct of empathy. Additionally, CITs would have less experience working with clients compared to experienced counselors, and thus less time for feelings of compassion fatigue to build.

 

Although scholars addressed the importance of supervision and supervisory working alliance to help prevent compassion fatigue (Kapoulitsas & Corcoran, 2015; Merriman, 2015a), this study’s results indicated supervisory working alliance was not a significant predictor of compassion fatigue among CITs. Like current results, Ivicic and Motta (2017) and Williams, Helm, and Clemens (2012) found no statistically significant association between supervisory working alliance and compassion fatigue among mental health practitioners. It is noteworthy that these studies highlighting the importance of supervision and the supervisory relationship are qualitative in design, and participants did not consist solely of CITs. Additionally, their results emphasized the importance of supervision as support to counter the negative impact of trauma exposure (Kapoulitsas & Corcoran, 2015; Ling, Hunter, & Maple, 2014). According to the current study results, CITs did not report experiencing a high level of compassion fatigue. This finding could be interpreted as CITs not yet feeling the need for supervisory support to help with compassion fatigue.

 

Results also indicated that resilience and wellness were significant predictors of compassion fatigue among CITs. In other words, when reflecting on both the regression and correlation results, CITs with greater resilience and wellness reported lower scores of compassion fatigue and these results were consistent with Tosone, Minami, Bettmann, and Jasperson’s (2010) research findings. Regarding a wellness and compassion fatigue relationship, Beaumont and colleagues (2016) conducted a study with student counselors and student cognitive behavioral psychotherapists. The results of Beaumont et al.’s study revealed that individuals with high scores of self-compassion and well-being reported having less compassion fatigue and burnout. Thomas and Morris (2017) also highlighted the significance of self-care and well-being not only for preventing and helping to manage the potentially damaging impact of practice, but also for facilitating the counselor’s personal and professional growth.

 

Implications for Counselor Educators and Supervisors

 

The research findings provide data-driven results regarding compassion fatigue among CITs that have meaningful implications for counselor educators and supervisors. Present study results revealed that CITs indicated experiencing a low risk of compassion fatigue. However, raising awareness on this issue may still help CITs as a preventative measure to cope with possible compassion fatigue experience in the future. To address this issue, counselor educators may consider raising awareness on this topic by reviewing current counseling program curricula to add discussion questions related to compassion fatigue and its empirically predictive factors—wellness and resilience. Roach and Young (2007) stated that students in counseling programs reported group counseling, counseling techniques, legal and ethical issues, practicum, and wellness courses as contributing most to their knowledge and skills regarding wellness. Therefore, counselor educators might use different assignments, including group discussions, projects, and role-playing exercises, to open a discussion about the compassion fatigue phenomenon and the relation with its predictive factors and these courses. Counselor educators may also use the ProQOL scale as an assignment in an assessment and testing course to inform CITs about how to use this instrument as a self-monitoring aid. For example, professional counselors may feel overwhelmed because of working with trauma survivors after graduation and start noticing compassion fatigue symptoms in themselves. These individuals may self-administer the ProQOL scale to determine whether they have developed compassion fatigue. Additionally, in a practicum or an internship course, CITs may fill out the ProQOL as part of their continuing personal wellness plan by comparing personal results over time and sharing their thoughts and reflections about the results.

 

Supervisors need to find ways to raise awareness of compassion fatigue and its protective factors with CITs. For instance, during internship experience, supervisors may develop a site training including compassion fatigue awareness for CITs, as CITs should be prepared for the possible emotional and psychological consequences in working with trauma survivors. Student counselors also should be encouraged to advocate for themselves when they notice symptoms of compassion fatigue. Supervisors might consider the administration of the ProQOL scale regularly to assess both organizational and individual risks (Newell & MacNeil, 2010). Additionally, supervisors can use the ProQOL scale with their supervisees to start a conversation about compassion fatigue. Although the ProQOL is not a diagnostic test, the 30-item self-report scale can be utilized readily as a conversation starter in supervision sessions.

 

The results suggested that empathy and supervisory working alliance did not predict CITs’ compassion fatigue level. However, wellness and resilience are significantly related to contributing to it. Therefore, both counselor educators and supervisors might consider enhancing CITs’ resilience and wellness a worthwhile endeavor. For example, Miller and Sprang (2017) developed a component-based practice and supervision model to reduce compassion fatigue for use in training, supervision, and clinical practice. A tool like this one can be added to existing training curricula and supervision practice to improve CITs’ resilience and wellness.

 

Limitations

The results of this study aim to provide greater clarity regarding the predictive factors of compassion fatigue among CITs. However, interpretation of results should take into consideration the limitations that emerged because of uncontrollable influences and choices we made. The study was limited in its ability to represent all CITs throughout the United States, as we utilized a convenience sampling approach. Additionally, we gathered data through self-report questionnaires, which introduce the possibility of response bias in the findings. Although we assumed participants answered each question honestly, they might not have been honest in their responses because of the fear of being perceived as weak or less competent. It is important to note that being in an internship class might also increase participants’ interest in the profession as they currently are engaged in the practice of counseling. Therefore, participants might have had a higher level of enthusiasm and reported less compassion fatigue. Also, individuals who suffer from compassion fatigue might have preferred not to respond to these items. Finally, although participants were enrolled in an internship class, each participant may have different numbers of hours of client experience.

 

Future Directions for Research

Additional research should be conducted to expand and clarify the current research findings of compassion fatigue among CITs. A phenomenological study using a qualitative research method is recommended to expand the findings of this current study. Future researchers may use the ProQOL scale to assess CITs’ level of compassion fatigue and then conduct interviews with the volunteer participants reporting a higher level of compassion fatigue to better understand CITs’ experience with compassion fatigue and its contributing factors. The data collected through a qualitative study may provide greater insight into the phenomenon of compassion fatigue among CITs. Additionally, researchers can replicate the present study with early-career counselors who have recently graduated, because of the noted intensity of those first years after graduation (Skovholt & Trotter-Mathison, 2016). Therefore, future researchers exploring novice counselors’ experiences with compassion fatigue will help counselor educators and supervisors better understand when counselors may start developing compassion fatigue symptoms, as well as how they cope with the symptoms.

 

Conclusion

 

CITs may struggle when they continuously hear painful stories of clients because of a lack of experience, skillset, or support (Skovholt & Trotter-Mathison, 2016). Researchers have described this experience as compassion fatigue. With this study, we aimed to provide a better understanding of the predictive factors of compassion fatigue among CITs. Using data-driven research results to determine ways to work with CITs on compassion fatigue and its predictive factors can be beneficial in preventing compassion fatigue symptoms from an early onset. CITs may take precautionary measures to ensure they remain enthusiastic and energized by the work they do. Further, implications of the current study may help CITs start their professional careers better prepared to provide their clients with the optimal care needed throughout the counseling relationship by minimizing compassion fatigue.

 

 

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.

 

 

 

References

 

American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author.

Beaumont, E., Durkin, M., Martin, C. J. H., & Carson, J. (2016). Measuring relationships between self-compassion, compassion fatigue, burnout and well-being in student counsellors and student cognitive behavioural psychotherapists: A quantitative survey. Counselling & Psychotherapy Research, 16, 15–23. doi:10.1002/capr.12054

Blount, A. J., Bjornsen, A. L., & Moore, M. M. (2018). Work values, occupational engagement, and professional quality of life in counselors-in-training: Assessments in a constructivist-based career counseling course. The Professional Counselor, 8, 60–72. doi:10.15241/ajb.8.1.60

Bride, B. E., Jones, J. L., & MacMaster, S.A. (2007). Correlates of secondary traumatic stress in child protective services workers. Journal of Evidence-Based Social Work, 4(3/4), 69–80. doi:10.1300/J394v04n03_05

Caringi, J. C., Hardiman, E. R., Weldon, P., Fletcher, S., Devlin, M., & Stanick, C. (2017). Secondary traumatic stress and licensed clinical social workers. Traumatology, 23(2), 186–195. doi:10.1037/trm0000061

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

Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimensional approach. Journal of Personality and Social Psychology, 44, 113–126. doi:10.1037/0022-3514.44.1.113

Diener, E., Wirtz, D., Tov, W., Kim-Prieto, C., Choi, D., Oishi, S., & Biswas-Diener, R. (2010). New measures of well-being: Flourishing and positive and negative feelings. Social Indicators Research, 39, 247–266. doi:10.1007/978-90-481-2354-4_12

Eastwood, C. D., & Ecklund, K. (2008). Compassion fatigue risk and self-care practices among residential treatment center childcare workers. Residential Treatment for Children & Youth, 25, 103–122. doi:10.1080/08865710802309972

Efstation, J. F., Patton, M. J., & Kardash, C. M. (1990). Measuring the working alliance in counselor supervision. Journal of Counseling Psychology, 37, 322–329. doi:10.1037/0022-0167.37.3.322

Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41, 1149–1160. doi:10.3758/brm.41.4.1149

Field, A. (2013). Discovering statistics using IBM SPSS statistics (4th ed.). Thousand Oaks, CA: SAGE.

Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Routledge.

Figley, C. R. (Ed.). (2002). Treating compassion fatigue. New York, NY: Brunner-Routledge.

Ganske, K. H. (2007). The relationship between counselor trainee perfectionism and working alliance with supervisor and client. (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses database. (UMI No. 3377933)

Harr, C. (2013). Promoting workplace health by diminishing the negative impact of compassion fatigue and increasing compassion satisfaction. Social Work & Christianity, 40, 71–88.

IBM Corporation. (2011). IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: Author.

Ivicic, R., & Motta, R. (2017). Variables associated with secondary traumatic stress among mental health professionals. Traumatology, 23, 196–204. doi:10.1037/trm0000065

Kapoulitsas, M., & Corcoran, T. (2015). Compassion fatigue and resilience: A qualitative analysis of social work practice. Qualitative Social Work: Research and Practice, 14, 86–101. doi:10.1177/1473325014528526

Knight, C. (2010). Indirect trauma in the field practicum: Secondary traumatic stress, vicarious trauma, and compassion fatigue among social work students and their field instructors. The Journal of Baccalaureate Social Work, 15, 31–52.

Lawson, G., & Myers, J. E. (2011). Wellness, professional quality of life, and career-sustaining behaviors: What keeps us well? Journal of Counseling & Development, 89, 163–171. doi:10.1002/j.1556-6678.2011.tb00074.x

Lawson, G., Venart, E., Hazler, R. J., & Kottler, J. A. (2007). Toward a culture of counselor wellness. The Journal of Humanistic Counseling, Education and Development, 46, 5–19. doi:10.1002/j.2161-1939.2007.tb00022.x

Ling, J., Hunter, S. V., & Maple, M. (2014). Navigating the challenges of trauma counselling: How counsellors thrive and sustain their engagement. Australian Social Work, 67, 297–310.
doi:10.1080/0312407X.2013.837188

MacRitchie, V., & Leibowitz, S. (2010). Secondary traumatic stress, level of exposure, empathy and social
support in trauma workers. South African Journal of Psychology, 40, 149–158. doi:10.1177/008124631004000204

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

Merriman, J. (2015b). Prevention-based training for licensed professional counselor interns. Journal of Professional Counseling: Practice, Theory & Research, 42, 40–53.

Miller, B., & Sprang, G. (2017). A components-based practice and supervision model for reducing compassion fatigue by affecting clinician experience. Traumatology, 23, 153–164. doi:10.1037/trm0000058

Newell, J. M., & MacNeil, G. A. (2010). Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue: A review of theoretical terms, risk factors, and preventive methods for clinicians and researchers. Best Practices in Mental Health: An International Journal, 6, 57–68.

O’Brien, J. L., & Haaga, D. A. F. (2015). Empathic accuracy and compassion fatigue among therapist trainees. Professional Psychology: Research and Practice, 46, 414–420. doi:10.1037/pro0000037

Péloquin, K., & Lafontaine, M. (2010). Measuring empathy in couples: Validity and reliability of the
Interpersonal Reactivity Index for couples. Journal of Personality Assessment, 92, 146–157. doi:10.1080/00223890903510399

Ray, S. L., Wong, C., White, D., & Heaslip, K. (2013). Compassion satisfaction, compassion fatigue, work life conditions, and burnout among frontline mental health care professionals. Traumatology, 19, 255–267. doi:10.1177/1534765612471144

Roach, L. F., & Young, M. E. (2007). Do counselor education programs promote wellness in their students? Counselor Education & Supervision, 47, 29–45. doi:10.1002/j.1556-6978.2007.tb00036.x

Rønnestad, M. H., & Skovholt, T. M. (2013). The developing practitioner: Growth and stagnation of therapists and counselors. New York, NY: Routledge.

Skovholt, T. M., & Trotter-Mathison, M. (2016). The resilient practitioner: Burnout and compassion fatigue prevention and self-care strategies for the helping professions (3rd ed.). New York, NY: Routledge.

Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Bernard, J. (2008). The Brief Resilience Scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15, 194–200. doi:10.1080/10705500802222972

Smith, H. L., Robinson, E. H. M., III, & Young, M. E. (2008). The relationship among wellness, psychological distress, and social desirability of entering master’s-level counselor trainees. Counselor Education & Supervision, 47, 96–109. doi:10.1002/j.1556-6978.2007.tb00041.x

Sprang, G., Clark, J. J., & Whitt-Woosley, A. (2007). Compassion fatigue, compassion satisfaction, and burnout: Factors impacting a professional’s quality of life. Journal of Loss and Trauma, 12, 259–280. doi:10.1080/15325020701238093

Stamm, B. H. (2010). The concise ProQOL manual (2nd ed.). Pocatello, ID: ProQOL.org.

Star, K. L. (2013). The relationship between self-care practices, burnout, compassion fatigue, and compassion satisfaction among professional counselors and counselors-in-training. (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses database. (UMI No. 3618924)

Thomas, D. A., & Morris, M. H. (2017). Creative counselor self-care. In Ideas and research you can use: VISTAS 2017. Retrieved from https://www.counseling.org/docs/default-source/vistas/creative-counselor-self-care.pdf?sfvrsn=4

Thomas, J. T., & Otis, M. D. (2010). Intrapsychic correlates of professional quality of life: Mindfulness, empathy, and emotional separation. Journal of the Society for Social Work and Research, 1(2), 83–98. doi:10.5243/jsswr.2010.7

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

Tosone, C., Bettmann, J. E., Minami, T., & Jasperson, R. A. (2010). New York City social workers after 9/11: Their attachment, resiliency, and compassion fatigue. International Journal of Emergency Mental Health, 12(2), 103–116.

Turgoose, D., Glover, N., Barker, C., & Maddox, L. (2017). Empathy, compassion fatigue, and burnout in police officers working with rape victims. Traumatology, 23, 205–213. doi:10.1037/trm0000118

Wagaman, M. A., Geiger, J. M., Shockley, C., & Segal, E. A. (2015). The role of empathy in burnout, compassion satisfaction, and secondary traumatic stress among social workers. Social Work, 60, 201–209.
doi:10.1093/sw/swv014

White, V. E., & Queener, J. (2003). Supervisor and supervisee attachments and social provisions related to the
supervisory working alliance. Counselor Education and Supervision, 42, 203–218.
doi:10.1002/j.1556-6978.2003.tb01812.x

Williams, A., Helm, H., & Clemens, E. V. (2012). The effect of childhood trauma, personal wellness, supervisory working alliance, and organizational factors on vicarious traumatization. Journal of Mental Health Counseling, 34, 133–153. doi:10.17744/mehc.34.2.j3l62k872325h583

Wood, A. E., Prins, A., Bush, N. E., Hsia, J. F., Bourn, L. E., Earley, M. D., . . . Ruzek, J. (2017). Reduction of
burnout in mental health care providers using the Provider Resilience mobile application. Community
Mental Health Journal
, 53, 452–459. doi:10.1007/s10597-016-0076-5

 

Nesime Can is an instructor at Ankara University in Turkey. Joshua C. Watson, NCC, is a professor and department chair at Texas A&M University–Corpus Christi. Correspondence can be addressed to Nesime Can, Ankara University Faculty of Educational Sciences, Department of Educational Sciences, Program of Counseling and Guidance, Office 3111, Çankaya, Ankara, Turkey 06590, nesime.can@ankara.edu.tr.

Counselors and Workplace Wellness Programs: A Conceptual Model

Yvette Saliba, Sejal Barden

Occupational stress is a top source of stress for over 65% of Americans due to extended hours in the workplace. Recent changes in health care have encouraged employers to build workplace wellness programs to improve physical and mental health for employees to mitigate the effects of occupational stress. Wellness programs focus on either disease management; treating chronic illnesses, such as hypertension and diabetes; lifestyle management; or preventing chronic illnesses through health promotion. This manuscript provides an overview of recent changes in health care and describes a conceptual framework, Steps to Better Health (S2BH), that counselors can use in workplace wellness programs. S2BH is an 8-week psychoeducational group based on the combination of motivational interviewing (MI) and the transtheoretical model of change (TTM).

 

Keywords: wellness, health care, workplace, stress, Steps to Better Health

 

Health and wellness are two concepts that have captured the attention of people throughout history. From Greek mythology to modern times, the idea of well-being has permeated society (Myers & Sweeney, 2007). Today, with the Patient Protection and Affordable Care Act (PPACA), health care is moving away from a disease treatment model and embracing a disease prevention model (PPACA, 2010). Although individuals typically do not invest in preventive health measures, many businesses and companies are eager to improve their health care programs for employees (Willis Towers Watson, 2017). These changes in health care are relevant to mental health providers, as a new focus on prevention has created opportunities for counselors to help effect lasting health changes among employees. Therefore, to fit into this paradigm shift, professional counseling should be strongly connected to prevention and wellness (Granello, 2013). This article discusses the changes in health care models, how those changes are creating spaces for mental health counselors to fill and implications for the counseling profession.

 

The Changing Landscape of Health Care

In 2015, the Kaiser Family Foundation released a report highlighting the rising cost of health care expenditures from 1960 to 2013. This report indicated that health care costs, which include total costs for hospital visits, physicians and clinics, as well as prescription medications, have risen from 27.4 billion dollars to over $2 trillion (Kaiser Family Foundation, 2015). Due in part to increases in the cost of health care and health insurance, the PPACA was passed into federal law in 2010. Mandates of the PPACA include: (a) preventing the denial of coverage for pre-existing conditions; (b) strengthening community health centers; (c) decreasing health disparities; (d) promoting integrated health systems; (e) connecting physician payments to the quality rather than the quantity of care provided; and (f) lowering long-term costs by providing free and more comprehensive preventive care (U.S. Department of Health and Human Services, Health Care, 2016). In a White House memo sent out during National Public Health Week in 2014, President Obama stated, “my administration is supporting efforts across our country to improve public health and shift the focus from sickness and disease to wellness and prevention” (Obama, 2014, p. 1).

This shift is clearly seen in the PPACA. Section 4001 of the PPACA, entitled “Modernizing Disease Prevention and Public Health Systems,” discusses ways in which health prevention should be carried out within the public sector (PPACA, 2010). This portion of the law includes a taskforce team that would: (a) evaluate wellness programs in 2013; (b) create the Prevention and Public Health Fund to distribute money to worksites establishing wellness programs; (c) further the education of health and wellness promotion; and (d) report on measures enacted that address lifestyle behavior modification (PPACA, 2010). Lifestyle behavior modification is defined as activities that include “smoking cessation, proper nutrition, appropriate exercise, mental health, behavioral health, substance use disorder, and domestic violence screenings” (PPACA, 2010, p. 422). In other words, initiatives from the federal government highlight the emphasis on prevention in both community and clinical health venues and extend this focus by supporting research into workplace wellness initiatives (Anderko et al., 2012). Though the PPACA encourages workplace wellness programs, many employers see the benefits to their employees even without federal regulations. In a recent survey, employers indicated they are still committed to better workplace wellness programs despite the unknown future of the PPACA (Willis Towers Watson, 2017). One primary motivator behind these programs is a reduction of employee stress through health promotion.

 

Health Promotion in the Workplace

According to the 2015 Bureau of Labor and Statistics report, Americans spent 8.8 hours a day at work or doing work-related activities (U.S. Department of Labor, 2016). Therefore, it can be estimated that Americans spend much of their lives in workplace settings, which can lead to occupation-related stress. In 2012, the American Psychological Association’s (APA) Stress in America Survey revealed that 65% of Americans reported work as a top source of stress (APA, 2016). Stress can affect a person’s emotional state, and it also can weaken the body’s ability to regulate itself after a stressful experience, which can eventually cause detrimental health consequences (Galla, O’Reilly, Kitil, Smalley, & Black, 2015). For example, the effects of chronic stress have been shown to lead to obesity and metabolic diseases (Razzoli & Bartolomucci, 2016). As a result, many individuals have resorted to maladaptive ways of coping with stress, highlighting the need for bringing stress management skills to the workplace (Galla et al., 2015). In addition, the World Health Organization has stated that health promotion in the workplace (promoting aspects of physical and emotional wellness) is beneficial in combating work-related stress (Jarman, Martin, Venn, Otahal, & Sanderson, 2015).

Finding ways to help employees manage their stress through health promotion in the workplace is typically conducted through workplace wellness programs, which include both lifestyle and disease management programs (Caloyeras, Hangsheng, Exum, Broderick, & Mattke, 2014; Kaspin, Gorman, & Miller, 2013; Mattke et al., 2013). Promoting positive health habits among employees maintains affordable health coverage and increases worker productivity (Anderko et al., 2012; Parkinson, Peele, Keyser, Liu, & Doyle, 2014; Shapiro & Moseley, 2013). Most workplace wellness programs focus on disease management, treating chronic illnesses such as diabetes and hypertension. Disease management programs also typically utilize health care professionals, such as nurses, to conduct face-to-face meetings or telephone consultations (Caloyeras et al., 2014). Conversely, lifestyle management programs prevent chronic illnesses by: (a) reducing stress; (b) lowering weight; (c) encouraging exercise; (d) promoting smoking cessation; and (e) fostering overall well-being (Caloyeras et al., 2014; Kaspin et al., 2013; Mattke et al., 2013).

 

Wellness Programs

Johnson & Johnson was an early pioneer in the creation and promotion of workplace wellness programs. In the 1970s, the company implemented a wellness program for employees called Live for Life (Ozminkowski et al., 2002). In 1993, this program was modified to integrate the following additional services: (a) employee health; (b) occupational medicine; (c) health promotion; (d) disability management; and (e) an employee assistance program. A modified program was rebranded with a new title: The Johnson & Johnson Health & Wellness Program (Ozminkowski et al., 2002). At the time of the program analysis, Johnson & Johnson employed approximately 40,000 people in the United States, 90% of whom participated in their wellness program. The program was evaluated by comparing outpatient doctor visits, hospital inpatient stays and mental health visits over the course of four years as compared to three years prior to the start of the wellness program. The worksite wellness program resulted in significant annual savings per employee/per year. On average, the study reported $45.17 savings for each outpatient visit, $119.67 per inpatient stays and $70.69 for mental health visits. In sum, Johnson & Johnson reported over $8 million in annual savings (Kaspin et al., 2013; Ozminkowski et al., 2002), creating a model wellness program that has been replicated in other organizations to varying degrees.

In contrast, PepsiCo offered a program in 2004 that did not produce similar results. Over 55,000 employees participated in a 3-year study, and it was determined that while costs were high in the initial year, it was the disease management portion of the program that lowered overall medical expenses by the third year (Liu et al., 2013). The disease management program was six to nine months in length and involved regular phone calls with a nurse for 15 to 25 minutes (Caloyeras et al., 2014). The program focused primarily on conditions such as asthma, coronary artery disease, congestive heart failure, hypertension and strokes (Caloyeras et al., 2014). Conversely, the lifestyle management portion of the program, which focused on weight management, nutrition management, fitness, stress management and smoking cessation, was described simply as involving a “series of telephonic calls with a wellness coach over a six-month period” (Caloyeras et al., 2014, p. 125). Training to become a wellness coach varies widely, ranging from a few days to 6 months. Training typically requires an associate degree and 18 weeks of classes conducted over the telephone or four full days of training in topics that include: (a) growth-promoting relationships; (b) expressing compassion; and (c) eliciting motivation to overcome ambivalence (Wellcoaches, 2016). The lack of sustainable changes in lifestyle wellness programs may be due to the variation and brevity of training for wellness coaches.

Hospitals have started employee wellness programs to lower employee health insurance costs, support mental health, and recruit and retain quality employees (Caloyeras et al., 2014; Hochart & Lang, 2011; Liu et al., 2013; Parkinson et al., 2014). Ironically, while the health care system is designed to help patients achieve good health, it often comes at the price of high stress levels and poor health for the employees (Chang, Hancock, Johnson, Daly, & Jackson, 2005; McClafferty & Brown, 2014; Smith, 2014). In fact, hospital employees tend to exhibit poorer health than other types of employees, which results in hospitals having the highest health care costs among employment sectors in the United States (Parkinson et al., 2014). As a result, some hospitals, such as the University of Pittsburgh Medical Center, are introducing the idea of employee wellness programs. In 2005, the University of Pittsburgh Medical Center utilized a prepackaged wellness program called MyHealth—a program that included both lifestyle and disease management components (Parkinson et al., 2014). Based on the number of requirements an employee met and activities he or she engaged in, the program provided credit that could be used to lower insurance deductibles (Parkinson et al., 2014). MyHealth consisted of online education materials, self-help tools, telephonic health coaching and support groups for lifestyle issues such as smoking cessation, depression, and emotional health and stress issues (Parkinson et al., 2014). Over a 5-year period, overall health care costs were lowered, but again, savings were attributed to the disease management portion of the program and not the lifestyle management portion (Caloyeras et al., 2014). Although there has been moderate success with wellness programs, the inclusion of counselors could make these programs more successful.

 

Need for Counselors in Wellness Programs

Changes in health care and increases in worksite wellness programs have created footholds for trained mental health professionals. As evidenced in the cases above, health care professionals, rather than mental health professionals, are facilitating lifestyle wellness programs. This is unfortunate, as professional counselors are trained in the skills of rapport building, demonstrating empathy and helping others achieve their goals. To build upon counselors’ inherent training and strengths may reduce the need for additional support and behavior change training. Utilizing counselors may result in stronger program implementation and cost savings for companies (Groeneveld, Proper, Absalah, van der Beek, and van Mechelen, 2011). Furthermore, although there have been some promising results and modest savings due to wellness programs, the variability in the content of wellness programs ranges widely. Therefore, it is proposed that having a program designed and led by counselors may have the potential to create larger savings for the lifestyle management portion of worksite wellness programs. With counselors utilizing their skills and coupling these techniques with aspects of motivational interviewing (MI) and the transtheoretical model of change (TTM), they could strengthen the lifestyle management portion of wellness programs and build on the foundation of wellness in counseling. To this end, we propose a psychoeducational lifestyle management conceptual framework that combines both MI and the TTM in an 8-week program, entitled Steps to Better Health (S2BH), which is described in the following section.

 

Components of S2BH

MI is an approach that helps individuals motivate themselves to pursue the changes that they seek. The founders of MI, Miller and Rollnick (2013), defined MI as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” (p. 12). More precisely, MI is about skillfully arranging conversations so that people talk themselves into changing (Miller & Rollnick, 2013). Further, MI has been positively correlated with stress reduction, medication adherence, diet change and exercise participation (Rollnick, Miller, & Butler, 2008). Miller and Rollnick (2013) asserted that people from all backgrounds could be trained to use the tools of MI; however, they emphasize that MI is not simply a collection of techniques (Miller & Rollnick, 2013). Rather, MI should be applied in a context that is characterized by client-counselor collaboration, client independence, and empowering clients to find and use their own resources for change (Young, Gutierrez, & Hagedorn, 2012). In addition to MI, the proposed wellness program integrates the TTM, an evidence-based model for change, and research on effective group work.

The TTM was developed by Prochaska and DiClemente (1982) to facilitate behavioral changes for individuals (Campbell, Eichhorn, Early, Caraccioli, & Greeley, 2012). The TTM consists of five stages of change individuals experience when changing behavior. The five stages are: (a) pre-contemplative (not thinking about change); (b) contemplative (thinking about change); (c) preparation (taking steps to begin change); (d) action (making the change); and (e) maintenance (creating a habit of new change; Shinitzky & Kub, 2001).

Prochaska et al. (2008) reviewed employee health promotion interventions, and results demonstrated that both MI and the TTM individually can lead to effective change. Participants (N = 1400) at a major medical university were assigned to three treatment groups: brief health risk intervention (BHRI) only (n = 433), online TTM-tailored treatment (n = 504), and an MI treatment group (n = 433; Prochaska et al., 2008). The results of the study showed that both the MI and TTM treatment groups had more individuals participating in the action stage for exercise and indicated better management of stress along with less health risk behaviors in 6 months than the BHRI only group (Prochaska et al., 2008). This study suggests that if both MI and TTM are effective separately, then combining them could lead to further success. Additionally, utilizing this combination within the framework of a psychoeducational group for a workplace would create efficiency.

Psychoeducational group work is ideal for a wellness program as it is a “hybrid of an academic course and counseling session” (Brown, 2011, p. 8). This format allows participants to feel as though they are attending a class, which can help them focus on learning and implementing a specific task without the potential stigma of therapy. For working professionals who may not feel the need to participate in traditional counseling, a psychoeducational group provides opportunity for discussions and activities in which individuals can practice various wellness techniques in a safe setting. Additionally, groups can be more cost-effective for businesses and organizations, as a number of individuals can simultaneously accomplish goals in a shared timeframe.

For many wellness programs, the results have been mixed due to expensive training and inadequate application of behavior change principles. For the lifestyle management portion of these wellness programs to be successful, a stronger framework would need to be implemented along with the use of professionally trained counselors. Therefore, a conceptual framework that counselors can consider adapting for a wellness lifestyle management program is proposed. The intention is to emphasize critical theoretical components while integrating practical ideas for counselors to build upon and adapt into their own lifestyle and health management programs.

 

S2BH

     The proposed intervention of S2BH is an 8-week pyschoeducational group that incorporates aspects of both MI and the TTM. Each session consists of a short lesson about a concept related to change followed by a discussion that progressively moves each participant toward making the decision to change and successfully enacting those changes. Devoting 1 hour per week over the span of 8 weeks would yield overall balance and wellness among employees, leading to higher work performance and lower absenteeism (Vitality Institute, 2014). In addition to group sessions, the counselor should be available for optional one-on-one follow-up sessions, up to two times after the initial 8 weeks, ideally at the employer’s expense. These sessions would provide the opportunity for employees to address specific wellness concerns to help maintain changes. For demonstration purposes, below is a brief case example that demonstrates how S2BH could be utilized. In addition, Table 1 contains an overview of the program.

 

Case Illustration

Polly, a 46-year-old oncology nurse for 20 years, and Amelia, a 35-year-old oncology nurse for 9 years, work at Metro Hospital, a 2,000-bed acute care medical facility located in a busy downtown area. Both Polly and Amelia were frustrated about their workloads and felt burned out because of job stressors. They were both interested in joining the S2BH group, as it would give them more points in Metro’s HealthyYou! Campaign. These additional points could later be translated into monetary bonuses to encourage employee participation. After gaining permission from their nurse manager to be part of the S2BH group, both women joined seven other nurses from different floors once a week for an hour during their lunch break. Both Polly and Amelia completed physicals as a part of the campaign, and despite weight and blood pressure issues, neither of the physicals for both women showed severe health concerns.

During their first meeting, Polly shared feeling fatigued and believing that her lack of exercise played a part in that. Amelia stated that though she managed to walk once a week, she still felt lethargic both emotionally and physically, but was not sure why. During this first group, the counselor utilized one of the central principles of MI, which reflects listening skills to express empathy and genuine caring for the nurses. To close the group, everyone received the S2BH Wellness Primer Worksheet as homework.

 

Table 1

Suggested Curriculum for Steps to Better Health

 

Weekly Session

Session Details

Activities in Session

Homework Assigned

Week 1: Rapport Building and Therapeutic Alliance

Counselor will welcome the group and explain the weekly format, with emphasis on goal attainment. Participants will be encouraged to share work-related stressors and wellness goals. A worksheet will be provided for participants to outline wellness goals, steps needed to achieve goals and identification of stressors.

Week 2:

Wellness Education

Participants will explore reasons for change and discuss the homework from the previous session. Participants will discuss potential pitfalls and necessary supports for successful change. Participants will identify what problems they encountered with their last change attempts.

Week 3:

The Stages of Change

Counselor will give lesson on TTM, focusing on the stages of change. Participants will identify which stage of change they are in and work to develop stage-matched interventions. Participants will write down the advantages and disadvantages of achieving their wellness goal(s).

Week 4:

Exploring Ambivalence

Counselor will lead a discussion on ambivalence (Miller & Rollnick, 2013; Shinitzky & Kub, 2001). Participants will discuss benefits and costs of not changing behavior. Each participant will identify one to two new habits as they move toward their wellness goal(s).

Week 5:

Habit Formation

Counselor will discuss how participants can create new habits. Using homework, members will identify cues/routines/rewards for each new habit identified (Duhigg, 2012). Each participant will bring to the next session a brief update on their wellness goal(s).

Week 6:

Reframing & Risk Assessments

Participants will discuss triggers and potential tactics to adhere to personal goals. Participants will identify and isolate potential triggers and solutions for the individual. Participants will identify stressors from work and life that could jeopardize wellness goal(s).

Week 7:

Stress Busters

Participants will discuss stress and ways to enhance coping skills (e.g., emotion-based and action-based). Participants will use homework to identify appropriate coping skills for each stressor. Participants will use one of the identified coping skills over the next week.

Week 8:

Wrap-Up

Participants will discuss how to stay motivated and engaged with wellness plans. Participants will discuss achievements followed by a termination activity. No homework assigned.

 

Polly and Amelia came back to the second group with their S2BH Wellness Primer Worksheet results and were a little hesitant to begin discussing their results. After a few other members shared, Polly stated that the wellness primer made her more aware of her lack of exercise. Amelia then shared that this was the first time she had sat down and reflected on her health and well-being, and though she was not sure it was necessarily helpful, she was willing to try anything to stop feeling “blah.” Following the discussion on the wellness primer, group members worked on developing a wellness plan for the areas they wanted to improve. To close the session, the counselor discussed with the members ways to begin working on their goals in incremental steps and noted different ways they had started addressing those steps.

After learning about the stages of change from the TTM in the third session, Polly was animated about which stage she was on in relation to her goal of exercising more. She shared that she had been stuck on the contemplative stage of change for more years than she could count. She stated that she wanted to lose weight but could not seem to motivate herself to walk before her shift started.

Amelia stated that she wanted to eat better and classified herself as being in the pre-contemplative stage of change. She reported that she needed to eat better because she relied too often on caffeine and sugary foods to keep her going throughout the work day. Several of the group members expressed hope in knowing that they were not just “being lazy,” but were in a process of change. Amelia stated that just knowing that gave her a boost of energy.

After checking in during the fourth session and finding out where everyone was with their goals, the counselor led a discussion on the MI concept of ambivalence. Polly found this a little challenging, as she just wanted to list the pros and cons of her new health goals: exercising and eating better. Once she understood that she was to list both the benefits and costs of continuing her current behavior versus enacting her new health goal, she became more involved in the activity. As a result, Polly listed some pros of walking in the morning as being “it centers me as I release some of the frustration from the day before,” and “I use this time to organize my mind for the upcoming tasks for the day.” Amelia stated that some of her cons for not changing her behavior included “crashing hard around 4 p.m. in the afternoon” and “losing focus when working with patients.”

For the fifth session, a discussion centered around Duhigg’s (2012) book, The Power of Habit: Why We Do What We Do in Life and Business, and how members could apply the principle of cue, reward and routine to help them achieve their goals. Polly stated that she started putting her walking shoes out with her exercise clothes so that she could immediately see them when she woke up (cue). She would play her favorite podcast while walking (routine), and reward herself with a small low-calorie pastry for breakfast (reward). Amelia stated that she started to place almonds and other energy-boosting snacks at the nurses’ station so she could easily see them (cue), then would snack on those items while talking with colleagues (routine). As a result, she felt her energy lasting longer throughout the day (reward).

The nurses enjoyed reframing their previous “relapses” in the sixth session. Amelia reported that she was aware it was normal to move back and forth between the stages and that this knowledge alleviated concerns about failure. The group had a lively discussion about what triggers or pitfalls stood in their way and what places or things they should avoid as a result. For example, Polly stated that if she hit the “snooze button,” she would stay in bed and forgo her walk. Realizing this, she opted to place her alarm clock across the room so that she would have to get out of bed to turn off the alarm.

The seventh session on stressors became more emotional than anticipated as many of the nurses talked about their work and the unique stress they experience when taking care of ill and terminally ill patients. The group members talked about their thoughts and feelings and supported one another during this session. As a result, a spontaneous sharing of how nurses deal with the grief of losing patients occurred. Amelia shared that she had recently decided to join Team in Training for the Leukemia and Lymphoma Society and train for a half marathon in memory of one of her younger patients. She stated that letting the family know and beginning to raise money for research in this area was helping her to positively channel her grief. As a result of this discussion, several of the nurses stated that they left the group with hope, connectivity, and ideas for channeling their grief and stress.

The final session of the group focused on closure. Amelia shared that although she was initially dubious about the group, as a result of her sharing and the small changes she was making with her snacking, she was not feeling as “blah” anymore. Polly also shared that while she had not lost weight yet, she felt more motivated to continue walking and noticed that she felt more positive about walking.

 

Conclusion

Changes in health care have increased job opportunities in health care for counselors. The PPACA allows counselors the opportunity to expand their background of wellness while capitalizing on preventive health care initiatives (Barden, Conley, & Young, 2015; Granello & Witmer, 2013). With the interrelatedness between physical and mental health, counselors are ideally positioned to help clients achieve their wellness goals. Connections between physical activity and psychological well-being are well established, as are the potential benefits of improved coping with stress and adversity (Focht & Lewis, 2013). Because chronic stress has been shown to contribute to obesity and metabolic diseases (Razzoli & Bartolomucci, 2016), helping employees improve their coping skills can lead to adaptive ways of dealing with stress, which ultimately impacts chronic health conditions. To better manage occupational stress, counselors can fill the need for bringing stress management skills to the workplace (Galla et al., 2015).

In addition, wellness programs provide the ability for counselors to research their contributions to workplace wellness programs, thereby providing an opportunity to study counselor effectiveness. Research has shown that using health care professionals in disease management portions of wellness programs can lower costs. The focus of this manuscript has been to describe a framework for counselors to facilitate lifestyle management programs in corporate settings. Considerable sponsored research opportunities also are available, especially for worksite wellness programs targeted to underserved populations (U.S. Department of Health and Human Services Office of Minority Health, 2016).

 

 

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.

 

References 

American Psychological Association. (2016). Coping with stress at work. Retrieved from http://www.apa.org/helpcenter/work-stress.aspx

Anderko, L., Roffenbender, J. S., Goetzel, R. Z., Millard, F., Wildenhaus, K., DeSantis, C., & Novelli, W. (2012). Promoting prevention through the Affordable Care Act: Workplace wellness. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 9. doi:10.5888/pcd9.120092

Barden, S., Conley, A., & Young, M. (2015). Integrating health and wellness in mental health counseling:

Clinical, educational, and policy implications. Journal of Mental Health Counseling, 37, 152–163.

doi:10.17744/mehc.37.2.1868134772854247

Brown, N. W. (2011). Psychoeducational groups, process and practice (3rd ed.). New York, NY: Routledge.

Caloyeras, J. P., Hangsheng, L., Exum, E., Broderick, M., & Mattke, S. (2014). Managing manifest diseases, but not health risks, saved PepsiCo money over seven years. Health Affairs, 33, 124–131.
doi:10.1377/hlthaff.2013.0625

Campbell, L., Eichhorn, K., Early, C., Caraccioli, P., & Greeley, A. (2012). Media use in the health care industry. American Journal of Health Studies, 27, 236–243.

Chang, E. M., Hancock, K. M., Johnson, A., Daly, J., & Jackson, D. (2005). Role stress in nurses: Review of related factors and strategies for moving forward. Nursing and Health Sciences, 7, 57–65.
doi:10.1111/j.1442-2018.2005.00221.x

Duhigg, C. (2012). The power of habit: Why we do what we do in life and business. New York, NY: Random House.

Focht, B. C., & Lewis, M. (2013). Physical activity and psychological well-being. In P. F. Granello (Ed.), Wellness counseling (pp. 104–117). Upper Saddle River, NJ: Pearson.

Galla, B. M., O’Reilly, G. A., Kitil, M. J., Smalley, S. L., & Black, D. S. (2015). Community-based mindfulness                  program for disease prevention and health promotion: Targeting stress reduction. American Journal of                     Health Promotion, 30, 36–41. doi:10.4278/ajhp.131107-QUAN-567

Granello, P. F. (2013). Wellness counseling. Upper Saddle River, NJ: Pearson.

Granello, P. F., & Witmer, J. M. (2013). The wellness challenge. In P. F. Granello (Ed.), Wellness counseling (pp. 2–10). Upper Saddle River, NJ: Pearson.

Groeneveld, I. F., Proper, K. I., Absalah, S., van der Beek, A. J., & van Mechelen, W. (2011). An individually based lifestyle intervention for workers at risk for cardiovascular disease: A process evaluation. American Journal of Health Promotion, 25, 396–401. doi:10.4278/ajhp.091001-QUAN-319

Hochart, C., & Lang, M. (2011). Impact of a comprehensive worksite wellness program on health risk, utilization, and health care costs. Population Health Management, 14, 111–116. doi:10.1089/pop.2010.0009

Jarman, L., Martin, A., Venn, A., Otahal, P., & Sanderson, K. (2015). Does workplace health promotion contribute to job stress reduction? Three-year findings from Partnering Healthy@Work. Biomed Central Public Health, 15(1293), 1–10. doi:10.1186/s12889-015-2625-1

Kaiser Family Foundation. (2015). [Graph illustration U.S. Health Expenditures 1960–2014, December 7, 2015]. Peterson-Kaiser Health System Tracker, Health Spending Explorer. Retrieved from http://www.healthsystemtracker.org/interactive/health-spending-explorer/?display=U.S.%2520%2524%2520Billions&service=Hospitals%252CPhysicians%2520%2526%2520Clinics%252CPrescription%2520Drug

Kaspin, L. C., Gorman, K. M., & Miller, R. M. (2013). Systematic review of employer-sponsored wellness

strategies and their economic and health-related outcomes. Population Health Management, 16, 14–21. doi:10.1089/pop.2012.0006

Liu, H., Harris, K., Weinberger, S., Serxner, S., Mattke, S., & Exum, E. (2013). Effect of an employer-sponsored health and wellness program on medical cost and utilization. Population Health Management, 16, 1–6. doi:10.1089/pop.2011.0108.

Mattke, S., Liu, H., Caloyeras, J. P., Huang, C. Y., Van Busum, K. R., Khodyakov, D., & Shier, V. (2013). Workplace wellness programs study. (Final Report). Santa Monica, CA: RAND Corporation. Retrieved from http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR254/RAND_RR254.pdf

McClafferty, H., & Brown, O. W. (2014). Physician health and wellness. Pediatrics, 134, 830–835.

doi:10.1542/peds.2014-2278

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: The Guilford Press.

Myers, J. E., & Sweeney, T. J. (2007). Wellness in counseling: An overview. (ACAPCD-09). Alexandria, VA: American Counseling Association.

Obama, B. (2014). Presidential Proclamation—National Public Health Week, 2014 [White House Memo]. Retrieved from https://obamawhitehouse.archives.gov/briefing-room/presidential-actions/

proclamations

Ozminkowski, R. J., Ling, D., Goetzel, R. Z., Bruno, J. A., Rutter, K. R., Isaac, F., & Wang, S. (2002). Long-term impact of Johnson & Johnson’s health and wellness program on health care utilization and expenditures. Journal of Occupational and Environmental Medicine, 44, 21–29. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11802462

Parkinson, M. D., Peele, P. B., Keyser, D. J., Liu, Y., & Doyle, S. (2014). UPMC MyHealth: Managing the health and costs of U.S. healthcare workers. American Journal of Preventive Medicine, 47, 403–410.
doi:10.1016/j.amepre.2014.03.013.

Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010).

Prochaska, J. O., Butterworth, S., Redding, C. A., Burden, V., Perrin, N., Leo, M., Flaherty-Robb, M., & Prochaska, J. M. (2008). Initial efficacy of MI, TTM tailoring and HRI’s with multiple behaviors for employee health promotion. Preventive Medicine, 46, 226–231. doi:10.1016/j.ypmed.2007.11.007

Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19, 276–288.

Razzoli, M., & Bartolomucci, A. (2016). The dichotomous effect of chronic stress on obesity. Trends in

Endocrinology & Metabolism, 27, 504–515. doi:10.1016/j.tem.2016.04.007

Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York, NY: The Guilford Press.

Shapiro, V., & Moseley, K. (2013). The real value of wellness programs: A comprehensive review of the literature. Population Health Management, 16, 283–284. doi:10.1089/pop.2013.1641

Shinitzky, H. E., & Kub, J. (2001). The art of motivating behavior change: The use of motivational interviewing to promote health. Public Health Nursing, 18, 178–185. doi:10.1046/j.1525-1446.2001.00178.x

Smith, S. A. (2014). Mindfulness-based stress reduction: An intervention to enhance the effectiveness of nurses’ coping with work-related stress. International Journal of Nursing Knowledge, 25, 119–130.
doi:10.1111/2047-3095.12025

U.S. Department of Health and Human Services, Health Care. (2016). About the affordable care act. Retrieved from http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/how-we-build-a-better-health-system/index.html

U.S. Department of Health and Human Services Office of Minority Health. (2016). Grant program: State partnership initiative to address health disparities (SPI). Retrieved from https://www.minorityhealth.hhs.gov/omh/content.aspx?lvl=2&lvlid=66&ID=126

U.S. Department of Labor. (2016). Charts from the American Time Use Survey. Retrieved from https://www.bls.gov/tus/charts

Vitality Institute. (2014). Investing in prevention: A national imperative. Retrieved from http://thevitalityinstitute.org/site/wp-content/uploads/2014/06/Vitality_Recommendations2014.pdf

Wellcoaches. (2016). School of Coaching. Retrieved from http://wellcoachesschool.com/core-coach-training

Willis Towers Watson. (2017). 21st Annual Willis Towers Watson best practices in health care employer survey. Retrieved from https://www.willistowerswatson.com/en/insights/2017/01/full-report-2016-21st-annual-willis-towers-watson-best-practices-in-health-care-employer-survey

Young, T. L., Gutierrez, D., & Hagedorn, W. B. (2013). Does motivational interviewing (MI) work with non-addicted clients? A controlled study measuring the effects of a brief training in MI on client outcomes. Journal of Counseling & Development, 91, 313–320. doi:10.1002/j.1556-6676.2013.00099.x

 

Yvette Saliba, NCC, is a doctoral student at the University of Central Florida. Sejal Barden, NCC, is an Associate Professor at the University of Central Florida. Correspondence can be addressed to Yvette Saliba, 851 South State Road 434, Suite #1070-170, Altamonte Springs, FL 32714, ysaliba@knights.ucf.edu.